PSYCHOLOGY

For the treatment of

the
clients coping with anxiety,
Hundreds of innovative exposures for panic, phobias, OCD,

big book
PTSD & more
treating anxiety & related disorders

I n cognitive behavioral therapy (CBT), exposures are the gold standard for

treating anxiety and related disorders, including obsessive-compulsive
disorder (OCD), panic, and phobias. But if you’re like many clinicians, you’ve
likely encountered clients who are fearful or reluctant to try exposure therapy the
big book
in session. As a result, you may shy away from doing exposures for fear of
worsening your client’s anxiety or rupturing the client/therapist rapport.
So, how can you move past “exposure phobia” to ensure the most effective
treatment available?

of
The Big Book of Exposures offers hundreds of innovative and easy-to-

of
implement exposure exercises you can use in any setting and adapt to your

EXPOSURES
clients’ unique needs. You’ll also find a comprehensive overview of exposure
therapy; a rationale for its use in treating anxiety; troubleshooting tips for

EXPOSURES
dealing with common roadblocks such as avoidance; and techniques for
helping clients stay motivated in session. With this essential resource, you’ll
learn to create engaging and enjoyable exposure exercises to improve
treatment outcomes and help your clients live better lives.

“A cornucopia of creative and effective exposure strategies for

a range of anxiety disorders…. If you’re in search of thoughtful
guidance on designing and implementing exposures,
add this book to your bookshelf.” Innovative, Creative & Effective CBT-Based Exposures
—Michael A. Tompkins, PhD, ABPP, author of Anxiety and Avoidance
for Treating Anxiety-Related Disorders
KRISTEN S. SPRINGER, PhD, is a licensed clinical psychologist with a private
practice in the greater Boston, MA, area, where she specializes in the assessment
and treatment of obsessive-compulsive disorder (OCD) and anxiety disorders in
Springer | Tolin
adolescents and adults.
Kristen S. Springer, PhD
DAVID F. TOLIN, PhD, is founder and director of the Anxiety Disorders Center
and the Center for Cognitive Behavioral Therapy at the Hartford Hospital Institute of David F. Tolin, PhD
Living in Hartford, CT. He is adjunct professor of psychiatry at Yale University School
of Medicine and maintains a private practice.

newharbingerpublications
w w w. n e w h a r b i n g e r . c o m
“The Big Book of Exposures is a cornucopia of creative and effective exposure strategies for
a range of anxiety disorders. The authors have cataloged hundreds of simple and effective
exposures that they’ve tested in their own clinical practices. The exposures worked for
them, and will work for you. If you’re in search of thoughtful guidance on designing and
implementing exposures, add this book to your bookshelf. You won’t regret it.”
—Michael A. Tompkins, PhD, ABPP, codirector of the San Francisco
Bay Area Center for Cognitive Therapy; assistant clinical professor at the
University of California, Berkeley; and author of Anxiety and Avoidance

“Exposure therapy—helping patients therapeutically face their fears—is the most effec-
tive intervention for treating clinical fear and anxiety, and Springer and Tolin have
amassed a comprehensive, practical guide to using this technique. Complete with loads
of creative exposure ideas and suggestions, this book is a must for any clinician working
with anxious and fearful individuals.”
—Jonathan S. Abramowitz, PhD, professor of psychology at The University
of North Carolina at Chapel Hill, and author of Getting Over OCD

“Drawing from their extensive clinical experience and research expertise, Springer and
Tolin have created an invaluable resource for both beginner and advanced clinicians who
use, or who would like to use, exposure therapy in their practice. This practical guide is
packed with evidence-informed, innovative recommendations for designing in vivo,
interoceptive, and imaginal exposures for children and adults with a range of anxiety and
related disorders. A ‘must-read’ for clinicians looking to expand their repertoire of clini-
cal skills.”
—Susan M. Orsillo, PhD, professor of psychology at Suffolk University,
and coauthor of The Mindful Way through Anxiety

“Confronting feared situations is among the most powerful approaches to treating anxiety
and related disorders. This well-written, accessible book is filled with practical tips for
conducting exposure therapy for the most common anxiety-related problems. This book
will even help therapists to overcome their own apprehension about using exposure
therapy, by addressing frequently occurring misconceptions and myths concerning expo-
sure. The Big Book of Exposures is essential reading for any therapist who treats anxiety
disorders, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD),
illness anxiety, and related problems—whether they are a student, novice clinician, or
seasoned therapist.”
—Martin M. Antony, PhD, ABPP, professor of psychology at Ryerson
University, and coauthor of The Shyness and Social Anxiety Workbook and
The Anti-Anxiety Workbook
 the
big book
of
EXPOSURES
Innovative, Creative & Effective CBT-Based Exposures
for Treating Anxiety-Related Disorders

Kristen S. Springer, PhD

David F. Tolin, PhD

New Harbinger Publications, Inc.

 Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the
subject matter covered. It is sold with the understanding that the publisher is not engaged in render-
ing psychological, financial, legal, or other professional services. If expert assistance or counseling is
needed, the services of a competent professional should be sought.

Distributed in Canada by Raincoast Books

Copyright © 2020 by Kristen S. Springer and David F. Tolin

New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com

Cover design by Amy Shoup

Acquired by Tesilya Hanauer

Edited by Rona Bernstein

Indexed by James Minkin

All Rights Reserved

Library of Congress Cataloging-in-Publication Data on file

Printed in the United States of America

22  21  20
10   9   8   7   6   5   4   3   2   1 First Printing
To my husband, Mike, who always said I would write a book. I never believed him.
This one is for you.—KSS

To Fiona, James, and Katie, and to all of the clients who have taught me over the
years.—DFT
 Contents

Introduction 1

PART I: An Overview of Exposure Therapy

Chapter 1 Anxiety, Avoidance, and Exposure 5
Chapter 2 Getting Clients on Board 15
Chapter 3 General Parameters of Exposure 27
Chapter 4 Helping Kids Climb the Exposure Ladder 53

PART II: Getting Creative with Exposures for Anxiety

and Related Disorders
Chapter 5 Specific Phobia 69
Chapter 6 Panic Disorder and Agoraphobia 105
Chapter 7 Social Anxiety Disorder 121
Chapter 8 Obsessive-Compulsive Disorder  139
Chapter 9 Acute Stress Disorder and Posttraumatic Stress Disorder 167
Chapter 10 Illness Anxiety Disorder 183
Chapter 11 Separation Anxiety Disorder 193
Acknowledgments 205
References 207
Index  215
 Introduction

I learned that courage was not the absence of fear, but the triumph over it. The brave man is
not he who does not feel afraid, but he who conquers that fear.
—Nelson Mandela

As clinical psychologists who specialize in, and conduct research on, anxiety and related
disorders, we have been using cognitive behavioral therapy (CBT) in our work to effec-
tively treat hundreds of clients with a range of disorders, such as phobias, panic disorder,
obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and more.
Our aim in writing this book is to help you use a critical, yet underutilized, element of
CBT for anxiety and related disorders: exposure. In this book, we have compiled hun-
dreds of exposures that we have used with clients. From our many experiences using
exposure in clinical settings, we have learned both the basics and the finer points of this
intervention. And we have taught many other clinicians what we know about taking
appropriate risks with exposures and getting creative with exposures to help clients target
their core fears and get the most out of treatment.
That being said, we also get stuck from time to time on how to best design and
implement an exposure for a particular client. That is what led to the development of this
book. If we need ideas for exposure, then we imagine that so do many others who may
not be using exposures regularly in their work. Therefore, we have created this book as
an easy-to-use and up-to-date guide—using criteria from the Diagnostic and Statistical
Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA],
2013)—with nearly 400 exposures for you to flip through and find the best ones to suit
each client.

WHO THIS BOOK IS FOR

This book is primarily written for behavioral health professionals and trainees in behav-
ioral health disciplines. We hope that whether you are a psychologist, social worker,
mental health counselor, psychiatrist, or student in training to become one of these
professionals, this book will be helpful for you in your treatment of clients with
2 The Big Book of Exposures

anxiety-related problems. The exposures in this book can be used to treat a range of
clients in a variety of settings, such as an outpatient mental health clinic, a private prac-
tice setting, a school setting, or an inpatient unit. We have designed this book to be
helpful to clinicians working with both younger and older client populations. Additionally,
for ease of reading, throughout this book we alternate between using male and female
pronouns in each chapter, but of course, regardless of the pronoun we use, the exposures
are suitable for clients of any gender.

HOW TO USE THIS BOOK

Part 1, “An Overview of Exposure Therapy,” is designed to provide you with information
about the empirical support for exposure with clients with panic, anxiety, phobias, OCD,
and trauma-related disorders. We discuss common misconceptions that mental health
providers may have about exposure work, aiming to help you solidify your rationale for
using it as a treatment of choice for various anxiety-related disorders. We provide infor-
mation and clinical vignettes to help you better engage fearful clients and to help them
get on board with treatment. The mere idea of exposure therapy can make some clients
(and clinicians) nervous or uncertain about what will take place and how it will go.
Therefore, we aim to help you overcome any barriers that might be in your way as you
move forward with delivering exposure therapy to your clients by outlining why it is safe
and effective to use this in your work with clients. We also include a chapter dedicated
to the nuances of doing successful exposure work with children and adolescents.
Part 2, “Getting Creative with Exposures for Anxiety and Related Disorders,” gets
into the diverse work that can be done with exposures. And, as you’ll see, it really is fun
work—creative, empowering, flexible, and, best of all, effective. We dedicate full chap-
ters to each of the anxiety-related disorders for which you will commonly use exposure as
a central component of treatment. These include specific phobias, panic disorder and
agoraphobia, social anxiety disorder, OCD, acute stress disorder and PTSD, illness
anxiety disorder, and separation anxiety disorder. Each chapter in part 2 includes many
innovative exposure ideas for you to use to best match your clients’ needs. In addition to
the exposure examples, each of the chapters in part 2 contains resources such as imagi-
nal scripts to use or adapt, games to play with your clients to target their fears, and more.
These resources, as well as some from earlier chapters, are also available on the website
dedicated to this book, http://www.newharbinger.com/43737, and can be downloaded,
printed, and used with your clients. (See the very back of this book for more details.)
We hope that you find the guidance and instruction in this book helpful in learning
not only how to use exposures successfully with your clients, but also how to get creative
with designing your own unique exposures and implementing them with confidence.
 PART I

An Overview of Exposure Therapy

 CHAPTER 1

Anxiety, Avoidance, and Exposure

Anxiety disorders are the most common mental disorders, substantially exceeding the
rate of depression, substance use disorders, and other conditions. In fact, nearly one third
of Americans have a lifetime history of one or more anxiety disorders (Kessler, Petukhova,
Sampson, Zaslavsky, & Wittchen, 2012). Therefore, it is important to disseminate effec-
tive treatments for anxiety to behavioral health providers. In this chapter, we will discuss
the negative impact of anxiety, the factors that contribute to the development and main-
tenance of anxiety, and how to treat anxiety using exposure therapy.

THE COST OF ANXIETY

Anxiety disorders are associated with significant functional, social, and economic
burden. DuPont et al. (1996) estimated that the total cost of anxiety-related disorders
was $46.6 billion in 1990, or 31.5% of the total economic burden of mental illness.
Anxiety-related disorders are also associated with significant reductions in health-related
quality of life (QOL) in the general population (Comer et al., 2011), in outpatient mental
health settings (Lochner et al., 2003), and in primary care medical settings (Beard,
Weisberg, & Keller, 2010). Across studies, individuals with anxiety disorders report much
poorer QOL than do control participants, and this appears to be true across diagnoses
(Olatunji, Cisler, & Tolin, 2007).
In addition to the burden of anxiety-related disorders on the individual, these disor-
ders often have a significant negative impact on families. For example, family members
of clients with OCD and PTSD report levels of distress, impairment, and burden compa-
rable to those reported by family members of patients with schizophrenia (Kalra, Kamath,
Trivedi, & Janca, 2008; Veltro, Magliano, Lobrace, Morosini, & Maj, 1994). There are
also high levels of distress in intimate relationships (Cooper, 1996; Jordan et al., 1992;
Riggs, Byrne, Weathers, & Litz, 1998). Family members often become ensnared in ritu-
alistic or avoidant behaviors at the insistence of the client, which can be time-consuming
and frustrating. In addition, the emotional and behavioral aspects of anxiety are associ-
ated with significant financial strain, disruption of family activities, and impaired family
interactions (Black, Gaffney, Schlosser, & Gabel, 1998; Calvocoressi et al., 1995; Van
Noppen & Steketee, 2003; Verbosky & Ryan, 1988). For these reasons, we often include
family members in the treatment of anxiety-related disorders, especially when working
with children and adolescents, an issue that we will address in chapter 4.
6 The Big Book of Exposures

WHAT IS ANXIETY?
Anxiety disorders can be conceptualized as an exaggerated pattern of fearful responding
that has a negative impact on the individual’s life. Fear is composed of physiological,
cognitive, and behavioral elements, which we will discuss below.

Anxiety and Physiology

Physiologically, fear is associated with sympathetic nervous system activity (also
known as the “fight-flight-freeze” response), mediated by the release of epinephrine into
the bloodstream. Signs of sympathetic arousal include elevated heart rate, rapid breath-
ing, sweating, muscle tension, and dry mouth. We think of the sympathetic nervous
system as functioning like an alarm system, which has become hypersensitive in indi-
viduals with anxiety-related disorders and must therefore be recalibrated. We will discuss
how we incorporate this information into psychoeducation in chapter 2.

Anxiety and Cognition

Cognitively, fearful responding can be characterized as maladaptive cognitive
content (what the person thinks) and maladaptive cognitive process (how the person
processes information). In terms of cognitive content, individuals with anxiety-related
disorders are thought to be prone to cognitive distortions (A. T. Beck, Emery, & Greenberg,
1985), such as probability overestimation (magnifying the likelihood of a low-probability
event) and catastrophizing (magnifying the impact or significance of a negative outcome,
or “making a mountain out of a molehill”). For example:
• An individual with a fear of dogs might assume that dogs, even friendly ones, are
going to bite him (probability overestimation).
• A client with social anxiety disorder might believe that if others see him sweat,
he will be humiliated and will never recover (catastrophizing).

In terms of cognitive process, anxiety-related disorders are associated with an atten-

tional bias toward threat-related cues (MacLeod, Mathews, & Tata, 1986): individuals
with anxiety-related disorders chronically, and involuntarily, scan the environment for
threat. For example:
• An individual with social anxiety giving a speech might disproportionately
focus on the least-receptive members of the audience while ignoring audience
members who appear more pleased and engaged in the speech.
• A client with PTSD related to interpersonal violence may constantly scan the
environment, looking for “threatening” people.
• An individual with panic disorder may be hyper-attentive to any signs of physi-
ological arousal, such as increased heart rate or lightheadedness.
Anxiety, Avoidance, and Exposure 7

Anxiety and Behavior

Behaviorally, anxiety-related disorders are characterized by various forms of avoid-
ance, and it is here that exposure therapy has its most direct impact. Some avoidance is
of external stimuli (activities, situations, objects, or people that are external to the client).
For example:
• An individual with agoraphobia might avoid driving or going to a crowded shop-
ping mall.
• A person with contamination-related OCD might avoid coming into contact
with things that appear dirty.
• A client with a specific phobia might avoid being near dogs, going to high places,
or flying.
• A client with social anxiety might avoid speaking in public or interacting with
others.
• An individual with motor vehicle accident-related PTSD might avoid driving on
the highway.
• A child with separation anxiety disorder might avoid situations that involve
being separated from caregivers, such as attending school.
• A client with illness anxiety disorder might avoid visiting the doctor for fear of
getting bad news.

Avoidance can also be of internal stimuli, such as thoughts, emotions, or bodily sen-
sations. For example:
• A person with panic disorder might go to great lengths to avoid experiencing
elevated heart rate or dizziness by limiting exertion, caffeine intake, or emo-
tional arousal.
• A client with PTSD might try to avoid memories of traumatic events.
• An individual with OCD might try to avoid “forbidden” or repugnant obsessive
thoughts.

Other forms of avoidance (which can be obvious or not so obvious) involve safety
behaviors: behaviors that the person feels will prevent a negative outcome or will reduce
feelings of anxiety. For example:
• If a client with OCD accidentally touches something “dirty,” he might wash his
hands repeatedly or mentally reassure himself.
• A person with social anxiety disorder might interact with others at a party, but
only after having a couple of drinks first.
• An individual with agoraphobia might go to the shopping mall, but only in the
presence of a trusted companion.
8 The Big Book of Exposures

• A client with motor vehicle accident-related PTSD may drive on the highway,
but only in the right lane, at a slow speed, in light traffic.

THE PROBLEM WITH AVOIDANCE

The impact of avoidance on fear is illustrated by a classic psychological experiment by
Solomon, Kamin, and Wynne (1953). In this study, the researchers conditioned dogs to
fear a light by shocking them at the same time that the light was turned on—a process
called fear conditioning. They then turned their attention to the process of fear extinction:
how the dogs “got over” the fear once it was learned. Fearful dogs were shown the “scary”
light again and again, this time with no shock. Presumably, when dogs viewed the light
over and over again, without being shocked, their fear would decrease. However, Solomon
et al. added a twist: one group of dogs was allowed to escape the situation by jumping
over a short wall; another group of dogs was not able to escape the situation. Results
indicated that the dogs who could escape the situation—those who could jump over the
wall and get away from the “scary” light—remained fearful indefinitely. Conversely, those
dogs who had to remain in the situation were able to overcome the fear.
What does this tell us about anxiety-related disorders in humans? It tells us that
avoidance tends to maintain fearful responding. The more we avoid, the more our fear
persists and may even worsen. On the other hand, cessation of avoidance—exposure—
leads to significant reductions in fear. Now, obviously, human clients are not identical to
dogs in an experiment. We can’t (and shouldn’t) force our clients to face their fears, or
physically prevent them from avoiding. But we can use our powers of persuasion to
accomplish a similar effect. We need to help our clients understand that avoidance is
part of the problem, and that exposure is the solution. In chapter 2, we will describe how
you can use psychoeducation and motivational interviewing to help clients arrive at that
conclusion.

WHY DO EXPOSURE THERAPY?

By encouraging clients to face their fears, we are undermining the pattern of avoidant
behavior and fearful responding. Exposure is thought to result in inhibitory learning, in
which the brain adjusts to new information by showing that feared consequences are
unlikely to occur and that distress is tolerable. We will discuss inhibitory learning in
greater depth in chapter 3. From a cognitive perspective, exposure therapy helps combat
the probability overestimation and catastrophizing associated with anxiety-related disor-
ders. For example:
• An individual with panic disorder learns that he can experience an elevated
heart rate without having a heart attack.
• The client with OCD learns that he does not become sick by touching “dirty”
things.
Anxiety, Avoidance, and Exposure 9

• A socially anxious individual learns that minor blunders do not lead to his being
ridiculed.
• The client with PTSD learns that he can remember the trauma without falling
apart.

Ultimately, of course, the best argument for conducting exposure therapy comes
from the clinical outcome data. Many well-conducted randomized controlled trials attest
to the efficacy of exposure-based therapy for anxiety-related disorders. Meta-analysis, in
which results from multiple studies are combined, demonstrates that exposure therapy is
efficacious across the anxiety-related disorders (Hofmann & Smits, 2008; Norton &
Price, 2007). Here are just a few examples from seminal research studies (italicized terms
will be discussed in greater detail in subsequent chapters):
• A series of clients with specific phobias received one long session of in vivo expo-
sure. At follow-up assessment (which ranged from 6 months to 7.5 years later;
average 4 years), 65% of clients were described as having completely recovered.
Another 25% were not recovered but were considered much improved (Öst,
1989).
• Individuals with social phobia were randomly assigned to receive a group CBT
incorporating in vivo exposure, phenelzine, or placebo. Here we will focus on the
efficacy of the exposure therapy. After twelve weeks of treatment, 75% of CBT
treatment completers, versus 41% of placebo treatment completers, were consid-
ered treatment responders. Exposure therapy and phenelzine had equivalent
response rates (Heimberg et al., 1998).
• Individuals with panic disorder were randomized to receive a CBT that priori-
tized interoceptive exposure and in vivo exposure, imipramine, combination treat-
ment, or placebo. Immediately after treatment, 49% of exposure recipients,
compared to 22% of placebo recipients, were considered treatment responders.
Six months after treatment discontinuation, 32% of exposure recipients, versus
13% of placebo recipients, were considered treatment responders. Exposure
therapy and imipramine had equivalent short-term effects, with some potential
advantage for combined treatment; however, after treatment was discontinued,
clients who received exposure therapy (with or without imipramine) showed a
lower rate of relapse (Barlow, Gorman, Shear, & Woods, 2000).
• Clients with OCD were assigned to receive exposure with response prevention,
clomipramine, combination treatment, or placebo. After twelve weeks of treat-
ment, 86% of those who completed exposure treatment, compared to 10% of
placebo recipients, were considered responders. Exposure therapy was superior
to clomipramine (Foa et al., 2005).

These results appear to hold up in “real-world” clinical settings as well as in aca-

demic research settings. In fact, across studies, exposure-based treatments conducted in
nonacademic clinics and hospitals, with clinically representative clients, seem to be
10 The Big Book of Exposures

about as effective as they are in more carefully controlled, laboratory-based trials (Hans
& Hiller, 2013; Stewart & Chambless, 2009).

The Perils of Exposophobia

Schare and Wyatt (2013) used the tongue-in-cheek term exposophobia to refer to “the
extreme fear (and associated avoidance) of using exposure therapy procedures occurring
in trained mental health professionals” (p. 252). Indeed, exposure therapy is grossly unde-
rused by mental health therapists (e.g., Becker, Zayfert, & Anderson, 2004; Goisman et
al., 1993). Given the solid theoretical and empirical background for the use of exposure
therapy in anxiety-related disorders, what might account for this underutilization? In
many cases, it appears that therapists fear upsetting the client or damaging the therapeu-
tic relationship. This is due, in part, to several myths about exposure (see Tolin, 2016),
described below.

Exposophobia Myth 1: Exposure will cause intolerable anxiety.

It is true that exposure, by design, produces temporary feelings of anxiety. However,
the available evidence shows that this increased anxiety is neither long-lasting nor intol-
erable, so long as the exposure is conducted thoughtfully and in collaboration with the
client. In one study of clients with PTSD, approximately one-quarter reported a tempo-
rary increase in feelings of anxiety in the days following exposure. Those who reported
an exacerbation of anxiety benefited just as much from the treatment in the long run as
did those whose anxiety did not increase (Foa, Zoellner, Feeny, Hembree, & Alvarez-
Conrad, 2002).

Exposophobia Myth 2: Exposure will increase co-occurring problems,

such as substance abuse.
Exposure therapy has been examined in clients with co-occurring PTSD and sub-
stance use disorders. These studies show that the clients reported reductions in substance
use, as well as reductions in their PTSD symptoms (Berenz, Rowe, Schumacher,
Stasiewicz, & Coffey, 2012; Brady, Dansky, Back, Foa, & Carroll, 2001; Mills et al., 2012).
We might opt to have dually diagnosed clients receive specialized substance abuse treat-
ment concurrently with exposure therapy, but the evidence doesn’t suggest that we
should avoid using exposure with such clients.

Exposophobia Myth 3: Exposure should not be used for PTSD,

childhood sexual abuse, or complex PTSD.
A wealth of empirical evidence shows that exposure therapy is effective in a wide
range of clients with PTSD, including motor vehicle accident survivors, combat veterans,
rape victims, and survivors of childhood sexual trauma (Powers, Halpern, Ferenschak,
Anxiety, Avoidance, and Exposure 11

Gillihan, & Foa, 2010). Indeed, exposure-based therapy has been identified as the only
psychological intervention with high strength of evidence for PTSD (Institute of
Medicine, 2008; Jonas et al., 2013), and it is considered a first-line treatment for clients
with complex PTSD (Cloitre et al., 2011). We’ll discuss exposure therapy for PTSD in
greater detail in chapter 9.

Exposophobia Myth 4: Exposure with children should be avoided.

Several studies demonstrate that children actually respond quite well to exposure-
based therapy (see Kendall et al., 2006). The efficacy of exposure therapy in children has
been demonstrated in children as young as preschool age (Lewin et al., 2014). Other
studies with children and adolescents show that exposure is effective in the treatment of
pediatric phobias (Ollendick et al., 2009), panic disorder (Pincus, May, Whitton, Mattis,
& Barlow, 2010), OCD (Franklin et al., 2015), and PTSD (Gilboa-Schechtman et al.,
2010). In chapter 4, we will talk more about specific applications of exposure therapy
with children.

Exposophobia Myth 5: Clients don’t want or can’t tolerate

exposure therapy.
Contrary to this myth, the evidence shows that clients find exposure acceptable.
When student trauma survivors and women with PTSD were given a choice between
exposure therapy and antidepressant medications, they were three to four times more
likely to choose exposure therapy than they were to choose medication (Becker, Darius,
& Schaumberg, 2007; Zoellner, Feeny, Cochran, & Pruitt, 2003). Furthermore, exposure
is not associated with increased dropout rates. Across studies of PTSD, clients are no
more likely to drop out of exposure therapy than they are to drop out of other psychologi-
cal treatments (Hembree et al., 2003). In studies where clients were assigned to receive
exposure vs. pharmacotherapy, dropout rates were generally equivalent (Barlow et al.,
2000; Foa et al., 2005; Heimberg et al., 1998).

Exposophobia Myth 6: Exposure therapy must be prefaced by

extensive coping skill training.
In our clinical experience, we find that many, if not most, clients do not require
coping skill training and can dive into exposure therapy right away. However, some
clients do require significant coping skill training, though this is more of the exception
rather than a rule. As one example, dialectical behavioral therapy (a CBT variant spe-
cifically designed for clients with borderline personality disorder and/or repeated self-
injurious behavior) employs exposure for PTSD symptoms but prefaces this exposure
with emotion regulation skill training (Linehan, 2014). Some studies of PTSD suggest
that coping skill training prior to exposure therapy may decrease dropout rates and
improve efficacy (Bryant et al., 2013; Cloitre et al., 2010).
12 The Big Book of Exposures

Going Beyond “Normal”

A common misconception of exposure therapy is that it is designed to mimic
“normal” human behavior. Certainly, some of the things our clients avoid, and to which
we want to expose them, are the kinds of things that people without anxiety disorders do
every day. In exposure therapy, we might ask our clients to perform “normal” behaviors,
such as:
• Driving
• Eating in a restaurant
• Talking to people
• Going to school or work
• Shopping in a mall

But we might also ask our clients to do some decidedly “abnormal” things, such as:
• Hyperventilating
• Listening to audio recordings of stories of traumatic experiences
• Touching a toilet with bare hands
• Talking to people after dabbing water on one’s forehead to simulate sweat

Why go to such lengths with exposure? Why not just prescribe “normal” behavior?
One reason is that it is difficult to predict what clients will encounter in real life, and we
want to make sure that our clients are adequately prepared for whatever experiences they
might have, even unanticipated ones. In addition, if you “overshoot” some of the expo-
sures by doing things that are more challenging than the client is likely to have to face in
everyday life, then the everyday tasks and roadblocks later on won’t seem so bad. This is
because the client will already have mastered much more challenging and higher-level
exposures. For example, if a client with OCD agrees to an exposure in which he touches
a toilet with his bare hands and then touches his face, hair, and clothes without washing
afterward, imagine how much easier it will be for him when he needs to ride the subway
to work, shake hands with someone, or use public bathrooms.
Second, and perhaps more critical, is the fact that low-grade exposures teach a
message of conditional safety (Otto, Simon, Olatunji, Sung, & Pollack, 2011): “I’m safe
if…” For example, a client with social anxiety might interact with others and learn the
conditional safety lesson “I’m safe if others don’t see me sweating.” A client with OCD
might use a public bathroom and learn the conditional safety lesson “I’m safe if my hands
don’t touch the toilet.” A client with panic disorder might go to the mall and learn the
conditional safety lesson “I’m safe if I keep my breathing under control and stay relaxed.”
We want the client to learn a lesson of unconditional safety: “I’m safe, period.”
Anxiety, Avoidance, and Exposure 13

A Note About Risk

After reading the last section, you might be wondering where we draw the line when
it comes to safety. Certainly, we do not want to create unnecessary risk of harm for our
clients. But we also don’t want to do subtherapeutic treatment. We find it helpful to talk
through these issues with our clients and to help them recognize that 100 percent safety
is an irrational goal. Part of living a happy life is being willing to tolerate certain risks.
Perhaps it’s helpful to think about all of the risks that are present, but that we don’t
even think of, during our day-to-day experience. Let’s imagine a typical client’s day. He
wakes up and, like many people with anxiety-related disorders, takes his antidepressant
or benzodiazepine medication. Then he gets in the car and drives on city streets or on a
highway to get to your office. He then has a session of exposure therapy with you. Which
is the most dangerous of these activities? Which is the least dangerous? It’s worth consid-
ering the fact that we routinely advise clients to take medications, despite the fact that
these medications can have significant adverse effects. And we routinely ask our clients
to drive to our office, despite the fact that motor vehicle accidents are a leading cause of
death. Now, to be clear, we are not anti-medication, nor are we anti-driving. We raise
these issues to make the point that life has risks, and we decide that certain risks are
worth taking. So it is with exposure therapy. Our aim in planning exposures is therefore
not to determine whether a given activity is 100 percent safe, but rather to determine
whether it is safe enough.

CONCLUSIONS
Many people will experience an anxiety-related disorder in their lifetime. This is often
accompanied by financial, social, and work-related distress. Fortunately, exposure therapy
is an empirically supported treatment that is used to help treat the anxiety, phobia, panic,
PTSD, or other disorder. Some clinicians have had misconceptions about using exposure
with clients (e.g., it could worsen anxiety, children aren’t able to handle it, or it is unsafe
to do unless clients are equipped with extensive coping skills). However, we have out-
lined why it is safe and effective to use this in your work with clients, and why it is impor-
tant to combat exposophobia.
The next chapter will be dedicated to pitching the idea of exposure therapy to your
client. One of the most important components of this “pitch” is to have confidence in
the treatment as well as in your delivery of the treatment. We will highlight the impor-
tance of providing psychoeducation to clients and working collaboratively with them.
Some clients may be ambivalent about making a change in their lives, so we will also
discuss principles of motivational interviewing.
 CHAPTER 2

Getting Clients on Board

Fundamentally, exposure therapy is about getting clients to do things that they would
rather avoid. That aim often requires a good deal of persuasion—in essence, “pitching”
the concept of exposure to a sometimes-skeptical client. CBT is a combination of art and
science, and there is definitely an art to the pitch. The pitch is important not only because
we want the client to choose exposure therapy, but also because we want the client to feel
confident in the treatment and comfortable with you as a therapist.
There are many different components to a good exposure pitch. These include:
• Providing your client with psychoeducation about her disorder, the model of
treatment, and the likelihood for success
• Establishing therapeutic rapport
• Using motivational interviewing strategies to assess the client’s stage of change
• Developing a collaborative working relationship
• Modeling exposures for the client

In this chapter, we’ll walk you through each of these steps.

USING PSYCHOEDUCATION
Psychoeducation doesn’t mean lecturing the client. Rather, psychoeducation involves a
back-and-forth conversation in which the therapist asks questions and provides informa-
tion to help the client understand the topic. Good psychoeducation regarding exposure
therapy involves providing the client with a model of anxiety and explaining how avoid-
ance is the enemy.

Providing a Model of Anxiety

CBT is based on the notion that fear (or any other emotion) can be conceptualized
as a triangle of thoughts, feelings, and behaviors (see figure 1). Fearful thoughts include
the probability overestimation and catastrophizing we mentioned in chapter 1. Clients
tend to believe that bad outcomes are highly likely, and they tend to believe that such bad
outcomes will be not merely bad; they will be disastrous, or catastrophic. Fearful feelings
16 The Big Book of Exposures

include the subjective emotional state of fear, along with the accompanying “fight-flight-
freeze” physiological reactions such as elevated heart rate, rapid breathing, sweating,
muscle tension, and dry mouth. Fearful behaviors include avoidance as well as safety
behaviors. The bidirectional arrows in figure 1 indicate that an increase in one compo-
nent tends to lead to increases in the other components. As people think more fearfully,
they tend to feel and behave more fearfully as well. As people feel more fearful, they tend
to think and act more fearfully. And as people behave more fearfully, their fearful
thoughts and feelings are maintained, thus creating a vicious cycle.
One of our first tasks is to help the client understand this triangle of thoughts, feel-
ings, and behaviors, which we refer to as the CBT triangle. Here’s an example of starting
the psychoeducation discussion with a client.

Therapist: I’m going to introduce what our treatment is going to look like, and I will
give you a chance to ask me any questions you may have. First, we need to
understand that all of our thoughts, feelings, and behaviors are linked
together. That is, this problem that you’re experiencing has something to do
with how you think, and something to do with how you feel, and something
to do with how you act. Does that make sense?

Client: I’m not sure. Can you explain what you mean?

Therapist: Here, let me draw this on a piece of paper (draws the diagram shown in
figure 1). You see here I have your thoughts, your feelings, and your behav-
iors all interconnecting. That’s what the problem looks like, if we break it
down. But let’s take it one piece at a time. The “thoughts” part refers to the
thoughts you have when something upsets you. These are the words or ideas
that go through your head. Can you think of some thoughts that you’ve had
when something bothered you?

Thoughts

Behaviors Feelings
Figure 1
Getting Clients on Board 17

Client: Yeah, I guess when I see something dirty, I think the germs are going to get
on me and make me sick. Is that what you mean?

Therapist: Yes, that’s exactly what I mean. How we think about things often plays a big
role in how we feel about them. For example, when you think that germs are
going to get on you, and you’re going to get sick, how do you feel then?

Client: I feel nervous and anxious.

Therapist: Okay, nervous and anxious. Those are feelings, and it’s very understandable
that you’d feel that way, if you’re thinking something’s going to make you
sick. I suspect a lot of people would feel anxious if they thought they were
going to get sick. And how we think and feel is closely linked to what we do.
So let’s come back to your example. Here you are, thinking that germs are
going to get on you, and you’re going to get sick. What do you do?

Client: Well, the main thing is that I don’t touch the thing that looks dirty.

Therapist: Exactly. So part of the behavior here is what you don’t do. You don’t touch
things that look dirty. We call that “avoidance.” And if you do feel like some
germs might be on you, what do you do then?

Client: I have to wash my hands over and over until they feel clean again.

Therapist: Yes, so another part of your behavior is what you do do. You wash your
hands. We call that a “safety behavior.” Can you imagine why we call it
that?

Client: Because it makes me feel safer?

Therapist: Yes, that’s it exactly. So you see that your thoughts, your feelings, and your
behaviors are all linked—and the therapy I have in mind for you is designed
to help all three of those components.

Making Avoidance the Enemy

Exposure therapy is designed to counteract the vicious cycle of avoidance and fear.
Remember, avoidance can be of external factors (e.g., certain situations, objects, or
people), or it can be of internal factors (e.g., certain thoughts, memories, or bodily sensa-
tions). Regardless of what is being avoided, the net result is the same—it is perceived as
more threatening over time, and the person is deprived of the opportunity to challenge
the fear and eventually overcome it. Therefore, in our psychoeducation, we take time to
help the client understand the toxic role of avoidance in maintaining the problem.

Therapist: I want to talk about avoidant behaviors a little more. You’ve mentioned that
you have some things that you don’t do, like not touching things that seem
18 The Big Book of Exposures

dirty, and some things that you do do, like washing your hands. What, do
you suppose, is the effect of those behaviors on your fear?

Client: Well, I know when I wash my hands I feel better. And it feels better not to
touch things that are dirty.

Therapist: Yes, so there’s a short-term relief from avoidance and safety behaviors, right?
You wash your hands and you feel better; you avoid and you feel better. How
about in the long term? What do you think is the long-term effect on you?

Client: I’m not sure I understand.

Therapist: Well, imagine it this way. Let’s say I am deathly afraid of, I don’t know, tuna
fish sandwiches. And I come to you as my therapist for help. Can you
imagine that?

Client: (laughs) Okay.

Therapist: And let’s say I’m really bothered by this fear. It’s really messing up my life
because I can’t go to anyone’s house where there might be a tuna fish sand-
wich, I can’t go to restaurants, and so on. With me so far?

Client: Yeah.

Therapist: So I tell you, my way of coping with this fear is to make sure I never go near
a tuna fish sandwich. Not only will I not go near them, I won’t look at them,
I won’t go anywhere there might be one, I won’t even say the word “tuna.”
And if I do accidentally see a tuna fish sandwich, I go home and take a
shower. All of these actions—this avoidance and these safety behaviors—
make me feel a little better. In the long run, what’s likely to happen to my
fear of tuna fish sandwiches?

Client: Well, I don’t think it’s going to go away.

Therapist: I don’t think so either. Why not?

Client: Well, because if you always avoid tuna fish sandwiches, then you’ll never get
to see that they’re okay and can’t hurt you.

Therapist: That’s exactly right. I never give myself a chance to learn anything differ-
ent. So my avoidance and my safety behaviors make me feel a little better in
the short term, but in the long term they actually hurt me and can even
make my fear of tuna fish sandwiches worse. Now let’s talk about your situ-
ation and use that same logic. Your avoidance and your safety behaviors
make you feel a little better in the short term, right? What, do you suppose,
is the long-term effect on you?

Client: They keep me afraid?

Getting Clients on Board 19

Therapist: Exactly right. They keep you stuck where you are. As long as you’re doing
these safety behaviors and this avoidance, you’re going to keep being afraid.
Now, as my therapist, what would you recommend for my tuna fish fear?
Should I keep avoiding and doing my safety behaviors?

Client: No, you should probably eat a tuna fish sandwich so you can get over it.

Therapist: I like where you’re going with this, but what if that’s just too scary for me
right now?

Client: Well, I suppose you could start small, like maybe just saying “tuna” or some-
thing like that.

Therapist: Ah, taking a gradual approach. I like that. What then?

Client: And then you could, for example, look at pictures of tuna fish sandwiches,
and then be around tuna fish sandwiches in real life, and eventually work
your way up to eating one.

Therapist: Yes, we can take it step by step until the goal is reached. And this is exactly
what we will be doing together to help you overcome your fears.

Explaining How Exposure Works

As you can see in the above example, the therapist has used a nonfrightening meta-
phor to segue into a discussion of graded exposure. Here, the therapist talks in more
detail about how the therapy will work.

Therapist: Let’s go back to this diagram of thoughts, feelings, and behaviors. A big goal
of our therapy is to break down the interactions among these three parts.
One of the main ways we will do this is through a strategy called exposure,
which targets the “behaviors” part of the triangle. Specifically, our job is to
identify those times where you’re likely to engage in avoidance or use a
safety behavior, and do the opposite—to approach, rather than avoid. The
“thoughts” component of the triangle is also important. I may ask you to
challenge some of the ways you think about things, or to test things out to
see if your way of thinking is accurate—to be on the lookout for evidence
that either confirms or contradicts some of the thoughts that you have.
Many times the evidence that we gather to challenge your thoughts will
come directly from the exposures that we do together. For example, if you
are afraid of touching contaminated items, like pens or door handles, since
you fear you could get sick, we may touch the things you are afraid of again
and again and again until your body and your brain learn that nothing bad
happens. Therefore, the exposure will likely change the way you think
about those contaminated items.
20 The Big Book of Exposures

Client: But why do it again and again? Can’t we just do the exposure once and be
done with it?

Therapist: I wouldn’t recommend doing that, and here’s why: if you complete an expo-
sure where you touch a door handle one time and you don’t get sick, your
brain may later think that nothing bad happened because that particular
door handle was okay and just happened to be “safe.” So, in a way, the expo-
sure that you may have worked so hard on in the session was discounted.
But, let’s say you touched 100 different door handles in the course of expo-
sure therapy. Then it would be pretty hard for your brain to discount them
all and say all of those exposures were “lucky” in that they weren’t contami-
nated or didn’t get you sick.

Client: That makes sense.

Having a Conversation About Fear

It is important to have a discussion with your client about the nature of fear. For
example, you might ask your client, “Do you think fear is harmful or dangerous?” Some
clients will know that it really isn’t dangerous, whereas others are convinced that fear or
physical arousal must be avoided at all costs. Some clients, particularly (though not
limited to) those with panic disorder or agoraphobia, may say that they fear the long-term
consequences of fear and think it could lead to a heart attack, accident, “going crazy,” or
other aversive outcome. This is why a discussion of the nature of fear is critical, as it
establishes an important piece of the foundation for your work together.
Fear is uncomfortable, but not dangerous. In fact, under the right circumstances,
fear can be quite adaptive. Here, the therapist uses psychoeducation to help the client
distinguish between adaptive and maladaptive fear.

Therapist: Obviously we’ve been talking about how your fear has caused problems for
you. But I also want to point out that fear, by itself, is not a bad emotion. It’s
actually helpful and necessary. Can you imagine what it would be like if a
person had zero fear—couldn’t even feel it?

Client: It sounds great, to be honest. I wish I had zero fear.

Therapist: It might seem great, but imagine what would happen if a person with zero
fear stepped into traffic and there was a car heading toward him?

Client: I guess he wouldn’t get out of the way and he’d get run over.

Therapist: Right. It’s fear, in measured doses, that gets you to jump back up onto the
sidewalk when you see a car coming. Some amount of fear is really impor-
tant. It keeps us on our toes and often protects us from harm. I really want
to emphasize that: fear is not inherently bad. The problem is that for some
people, the fear turns on when it doesn’t need to. It doesn’t wait for an
Getting Clients on Board 21

oncoming car, for example. It just turns on even when nothing dangerous is
happening. Let’s call that a “false alarm.” Your brain and body are having a
fear reaction even when there’s no danger. Part of our work during exposure
therapy will involve understanding when these false alarms are sounding,
and how to handle them differently from how you have handled them in the
past, such as through avoidance and safety behaviors.

You can have a discussion with your client about the various physiological symptoms
of anxiety and how they were designed to protect you. This list, adapted from Craske and
Barlow (2006), is a helpful guide:
• Increased heart and respiration rate functions to get more oxygenated blood to
the muscles associated with running.
• Tingling in the extremities or face (paresthesias) is a result of blood being redi-
rected toward the big muscle groups associated with flight.
• Sweating cools the body and makes it slippery (harder to catch).
• Dry mouth and stomach discomfort are the result of a partial shutdown of the
digestive system to free up energy for muscles, which will help the person fight
or flee.
• Lightheadedness and dizziness are often byproducts of hyperventilation, taking
more air into the body (which would be adaptive if the person were actually
running or fighting).

You may also talk with your client about the natural course of anxiety. What goes up
must eventually come down, meaning that anxiety can’t stay elevated forever. The body
is designed to protect you. Therefore, the anxiety will eventually lower on its own without
the client doing anything to make it come down.

Emphasizing Exposure’s Effectiveness

While you should be careful not to overpromise results, it’s important to point out
that this treatment really does work (as discussed in very abbreviated form in chapter 1).
Of course, success in treatment depends on many different factors. It depends on the
extent to which your clients do what you encourage them to do in session, as well as the
extent to which they complete homework assignments outside of the session. It also
depends on clients’ motivation level, level of confidence in the treatment, and other
factors that we, as therapists, can influence, such as our level of confidence in our clients
(which can greatly impact the confidence they have about themselves in the treatment),
how well we listen to our clients, and how well we work as a team to treat the disorder.
Here’s a script illustrating how to discuss the effectiveness of treatment with your client.

Therapist: Let’s talk a little bit about the effectiveness of exposure therapy. I wonder
whether any questions have come up for you about that.
22 The Big Book of Exposures

Client: Yeah, I was wondering how likely this is to be successful for me.

Therapist: The bottom line is that it’s highly likely to be successful for you. But I want
to clarify what I mean by “successful,” because it’s important that we have a
realistic understanding of what to expect. “Success,” in my view, doesn’t
mean that you’ll never feel fear again. As we discussed, fear is a very normal
human emotion, and it will be part of your life, just like it’s part of everyone
else’s life, forever. But what we can reasonably expect is that we can get this
fear “out of your face.” We can get it to the point where it’s no longer trou-
bling you day in and day out, that it no longer has control of your actions,
and that it no longer impairs your ability to do things you want to do. Does
that make sense?

Client: Yes. Will the results be permanent?

Therapist: Here’s what the scientific evidence tells us. First, when people have a good
response to exposure therapy, as I think you will, more often than not they
tend to continue showing a good response at long-term follow-up assess-
ments. That’s the good news. On the other hand, it’s also important to
understand what’s happening in exposure therapy at a very basic level.
Exposure doesn’t “erase” your fear or zap it out of your brain. It’s still in
there. Rather, through the course of exposure, you learn something new—
like how to cope by approaching, rather than avoiding—and that new habit
becomes stronger over time. But there is always a possibility that an old fear
habit can come back over time, in response to stress, or under new condi-
tions. Fortunately, our experience has been that if and when the fear pops
back up, you can get back on the program and get it back under control.

ESTABLISHING RAPPORT
No matter what your theoretical orientation is as a therapist, you know that rapport is
one of the most critical aspects of treatment. We want our clients to know that we seek
to understand what they are going through, appreciate their willingness to come to
therapy and try something new, and are confident that we can help them feel better.
Let your clients know that you want their feedback about treatment and about the
therapeutic relationship. This also shows your clients that you are interested in their
thoughts about how treatment is going and are willing to make corrective steps, if needed.
Be ready to be flexible and modify your treatment. If the rapport becomes ruptured in
any way, you should work to repair the rupture by directly addressing what happened,
taking nondefensive ownership for your role in the rupture, and asking for client feed-
back (for additional discussion see Safran, Muran, & Eubanks-Carter, 2011).
Getting Clients on Board 23

USING MOTIVATIONAL INTERVIEWING

A full discussion of motivational interviewing (MI) is outside the scope of this book; inter-
ested readers are directed to Miller and Rollnick (2013). MI is based on the idea that
motivation to change behaviors, engage in treatment, and take other actions can fluctu-
ate over time. At any given time, a client’s stage of change (Prochaska & DiClemente,
1982)—her awareness of the problem, readiness to work on it, and willingness to stick
with a treatment plan—could be defined as (a) precontemplation (not acknowledging the
problem or not being willing to change), (b) contemplation (“waffling,” being unsure
about whether or not to change the behavior), (c) action (deciding to work on the problem
and beginning the process of changing), or (d) maintenance (continuing to work on the
problem and trying to prevent backsliding).
A good way to think about MI is that our job, as therapists, is to escort the client
from one stage of change to the next. That is, if the client is in the precontemplation
stage, our job is to escort her to the contemplation stage; if the client is the contempla-
tion stage, our job is to escort her to the action stage; and if the client is in the action
stage, our job is to escort her to the maintenance stage.

Escorting the Client from Precontemplation

to Contemplation
The precontemplative client is stuck, and our job is to get her unstuck. We want to
get the discussion started, avoid argumentative pitfalls, and get the client considering
alternatives. Here are some helpful strategies:

Avoid argumentation. At this stage, resist the urge to try to convince the client
that she has a problem, or that she needs to do exposure therapy. Such efforts are
likely to just trigger counterarguments. Instead, simply get the client talking about
the issue.

Roll with resistance. When the client says something like “I don’t think I need
therapy,” don’t try to persuade her otherwise. Trying to persuade a precontempla-
tive client doesn’t seem to help, and it often backfires. Instead, try just reflecting
back what she said so the client knows you’ve heard it.

Develop discrepancy. Talk to you client about her larger goals and values—not
just as they relate to the presenting problem. What does your client want her life to
look like? What is truly important to her? Reflect this back to the client and ask
her to compare and contrast these goals and values with her current behavior,
which might sound like this: “It sounds like you’re in a tough spot right now. On
one hand, you’re not sure you like the idea of being in therapy, and you really don’t
like the idea of being labeled as having an ‘anxiety problem.’ On the other hand,
your work is very important to you, but you’re noticing that lately you have been
24 The Big Book of Exposures

avoiding talking to your colleagues and supervisor because of anxious feelings. I

wonder how you reconcile that.”

Escorting the Client from Contemplation to Action

The client in the contemplation stage is waffling. She is entertaining the idea that
there is a problem and/or that she needs help. Our job is to help this client decide what
to do. Here are the major strategies:

Weigh pros and cons. Get out a piece of paper and draw a line down the middle.
Label one side “pros,” and the other “cons.” Ask the client questions such as “What
would be some of the benefits or positives of doing this treatment?” “What would
be some of the costs or negatives?” “What would be the pros and cons of just
leaving things where they are?” “Which strategy is most likely to help you reach
your goals in life?”

Invite change talk. The philosopher Pascal (1623–1662) wrote, “People are better
persuaded by the reasons they themselves discovered than those that come into the
minds of others.” That is, the client, not the therapist, should make the argument
for changing. You can influence this by asking key questions such as “What makes
you think this is a problem?” or “What steps do you think you need to take in
order to feel better?”

Avoid uninvited prescriptions. The client in the contemplation stage may not be
ready to accept your opinion that she needs treatment, and that suggestion on your
part may just trigger a counterargument and send the client back to the precon-
templation stage. Offer an opinion only if asked, and if so, do it gently and try to
provide more than one option (e.g., CBT, medication management, self-help
books).

Escorting the Client from Action to Maintenance

The client in the action stage has made up her mind to start treatment. We now
want to get her actively working on the problem, which we do using the following two
strategies:

Make a plan. Work collaboratively with your client to develop the treatment plan,
including how many sessions you’ll have (at least a rough idea), how often you’ll
meet, what kinds of exposures you’ll do, and expectations for homework (yes, there
will be homework!). Make sure that the client feels like an active partner in this
process.

Periodically reassess stage of change. Don’t overestimate the client’s motivation.

Stages of change can be slippery, and it’s easy for a client in the action stage, for
Getting Clients on Board 25

example, to slide back into contemplation instead of forward into maintenance.

Therefore, watch for emerging signs of resistance and check in with the client
about her stage of change as needed.

COLLABORATING AS CO-SCIENTISTS
As the old saying goes, two heads are better than one, and this is certainly the case in
exposure therapy. Collaborative empiricism is a core aspect of CBT and enhances the
therapeutic relationship. Think of your client as your co-scientist, and be on the hunt
together to form and test hypotheses through exposure. Share with your client at the first
session that she will have a very active role in treatment. Your discussion with the client
may go something like this:

The two of us are going to work together in this treatment. While my expertise is in
treating anxiety disorders, you know your own anxiety much better than I ever will.
You know the ins and outs of it, what makes it worse, and what things you have
been doing to try to feel better. Therefore, I’ll ask you to share with me what is
working and what isn’t. This treatment is a team effort. I find the therapy is much
more effective, and easier to stick with, when we come up with ideas together and
give each other feedback.

Working together in this fashion not only builds rapport, but also allows the client to
learn how to be thinking and what to be doing outside of the session. One of the goals of
therapy is getting the client to feel well informed and confident enough to design and
implement her own exposures once the therapy has ended.

MODELING
It is preferable to do exposure with your clients, if at all possible. This can show them that
you are willing to take risks as well. For example, if you are asking a client with OCD to
walk into the bathroom with you and touch a germy toilet, then you had best be ready to
touch that toilet yourself! However, if it is clear that the client will have a much easier
time doing the exposure with you (perhaps because you are serving as a safety signal, a
sign that the exposure is safe), then you may want to consider having her do the exposure
by herself. For example, let’s say that your client has a fear of enclosed spaces and is about
to ride an elevator. You might opt to accompany the client into the elevator and ride with
her for a couple of sessions. However, it is possible that your presence becomes a safety
signal for the client (e.g., I know I’m going to be okay because my therapist is here and can
perform CPR if I have a heart attack or My therapist will know just what to do if this elevator
gets stuck). In such a case, subsequent exposures should be conducted without your
presence.
26 The Big Book of Exposures

CONCLUSIONS
In this chapter, we have discussed specific ways to get the client’s buy-in for exposure
therapy. This treatment is all about reversing old patterns of avoidant behavior, so
perhaps it’s not surprising that some clients require a bit of “selling.” The biggest element
of our pitch is psychoeducational. Most clients, once they understand the model of
anxiety and the relationships among thoughts, feelings, and behaviors—especially avoid-
ant behaviors—will readily understand that exposure is the way to go. Still, some clients,
quite understandably, are fearful about the prospect of replacing their avoidance with
approach. The motivational interviewing strategies of avoiding argumentation, rolling
with resistance, and developing discrepancy are quite helpful in persuading clients in the
precontemplation stage of change that they might need to reconsider their stance. For
contemplative clients, weighing pros and cons and inviting change talk while avoiding
uninvited prescriptions can help them settle on exposure as a preferred treatment strat-
egy. And for clients in the action stage, making a plan and not overestimating their
motivation will help them maintain their initiative. Finally, once the client is on board
with exposure, the strategies of collaborative empiricism and modeling will help keep the
client engaged.
In the next chapter, we will provide the basic guidelines for exposure. We will not
only give examples of the various types of exposures but will also describe how to best
implement them in session with your client.
 CHAPTER 3

General Parameters of Exposure

As we discussed in chapter 1, anxiety-related disorders are maintained, in part, by the

client’s avoidance of feared external and/or internal stimuli. In exposure therapy, our job
is to help our clients to face their fears systematically by repeatedly confronting feared
objects, activities, situations, thoughts, or feelings.
In this chapter, we will guide you through the various types of exposures and provide
instruction for implementing each type. We will also discuss models of exposure, includ-
ing the habituation model and the inhibitory learning model. When you read part 2 of this
book, which consists of exposure ideas for many anxiety-related disorders, we encourage
you to design and implement the exposures using the information included in this
chapter in order to best help your client have a successful exposure session.

TYPES OF EXPOSURE EXERCISES

There are four main types of exposures that can be used throughout therapy and that
we’ll discuss in this chapter:
• In vivo exposure
• Imaginal exposure
• Exposure to thoughts
• Exposure to body sensations (also known as interoceptive exposures)

In addition to the above-mentioned exposures, we address how to use virtual reality

in therapy. Virtual reality is another way to target feared sensations and thoughts as well
as allow the client to have a more immersive imaginal exposure experience.

In Vivo Exposure
In vivo exposure is the type of exposure that most easily comes to mind when think-
ing about exposure therapy. This form of exposure consists of directly confronting feared
situations in real life. In vivo exposures can be conducted with your client in or outside
of the therapy office or can be assigned to your client for homework.
28 The Big Book of Exposures

Examples of In Vivo Exposure

In vivo exposure can take countless forms. Some examples include:
• A client with a snake phobia holds a snake.
• A client with fear of flying goes on an airplane.
• A client with a fear of giving a speech in front of an audience.
• A client with OCD touches things that seem dirty or germy.

When designing in vivo exposures, make sure that they are safe for the client (and
you too!). We are not asking you to take your clients to dark alleys at night in big cities
with money hanging out of their pockets to target their fears of getting mugged or
attacked. Similarly, we are not asking you to take your client with a phobia of snakes into
the wild to try to provoke a dangerous snake. We do, however, want you to design chal-
lenging exposures with your clients. For your client with fears of being mugged, walking
through the city alone is likely a “safe enough” thing to do. For your client with a snake
phobia who won’t even go out into the garden for fear that a snake will be there, we want
him to work in her garden as an exposure and to take appropriate risks.

Guidelines for Setting up In Vivo Exposures

Sometimes with in vivo exposure, we ask clients to do things that are decidedly
abnormal. For example, if your client is afraid of germs and you want to expose her to
potential contaminants, you might ask her to touch trash dumpsters and then smear
those germs all over her clothes, hair, and face. Most people don’t do such things on an
everyday basis—but, as we discussed in chapter 1, we usually have to go beyond “normal”
behavior in order for your client to get better. So, yes, things can get a little odd. Here’s
an example of a conversation you could have with a client about what to expect when
moving forward with exposure therapy.

Therapist: I know you said that one of your main concerns is that you will vomit.
You’ve mentioned that you avoid talking about vomiting for fear that it will
make you throw up, and that you stay away from people who have been sick
because you’re concerned that they could contaminate you and make you
throw up.

Client: Yeah, that’s been my worst fear for a long time now. I’ve become really good
at avoiding all sorts of places in which I could get sick.

Therapist: I understand that has been really scary for you. Working together, we will
soon be creating a list, or hierarchy, of exposures that we will work on
together in session and that you will do outside of session for homework. For
example, we might begin with exposures of looking at pictures of vomit or
watching videos of people vomiting, and then move on to more challenging
exposures such as going near people who are sick or pretending to throw up.
General Parameters of Exposure 29

Client: I get that I will have to do some challenging things, but going near people
who are sick on purpose is kind of weird. I don’t know anyone else who has
to do that in their everyday life.

Therapist: That’s a great point. It’s important to recognize that some of the things we
do will seem kind of weird, and they won’t be what people typically do in
their everyday lives. Your anxiety tells you an awful lot of scary lies about
how bad things are and how sick you will get. The best way to fight back is
to confront your fear of getting sick that your anxiety doesn’t want you to
confront, including the really hard stuff, like sitting in a hospital waiting
room since there are likely to be people there who recently vomited. If we
just decided to stop treatment after you watched some videos of people vom-
iting, then I bet it would be pretty darn scary if you were later around a friend
who had recently had the flu or some other illness. If we can create challeng-
ing exposures now, then most things you will encounter naturally in the real
world will seem insignificant compared to what you have already mastered.

Client: That makes sense.

Therapist: Great. I do want to point out that I will never force you to do anything that
you don’t want to do or don’t feel ready to do. While I want each exposure
to be a challenge, I also want you to succeed.

Imaginal Exposure
When in vivo exposure is not possible or practical, such as with the client who fears
plane crashes or who has had a traumatic experience (e.g., assault, natural disaster), you
can use imaginal exposure. Imaginal exposure involves creating a narrative either on
paper, on a computer, or on a mobile device that the client will read aloud (or listen to a
recording of) repeatedly until the fear is reduced. In the narrative, you will want to the
client to include vivid details and to include as much sensory information as possible
(what the client sees, hears, and smells in the feared situation) to bring the fear into the
present moment for a powerful exposure.

Examples of Imaginal Exposure

The following are examples of imaginal exposure:
• A client with PTSD deliberately recalls the memory of a traumatic event in
vivid detail.
• An individual with OCD writes a detailed story about dying of a terrible disease
because he didn’t wash his hands.
• A client with a fear of flying deliberately imagines being on a violently turbulent
flight, records the story into his phone, and listens to it repeatedly.
30 The Big Book of Exposures

Imaginal exposure doesn’t have to be reserved for exposure items that can’t be recre-
ated in vivo. It can also be an important part of your client’s hierarchy of fears earlier in
treatment to help him gradually work up to doing in vivo exposure. For example, if your
client has a fear of contamination, you might consider doing an imaginal exposure in
which he writes a detailed story about becoming contaminated, how the contamination
occurred, and the feared outcome, such as contracting a disease. This may be a stepping-
stone toward later doing in vivo exposure in which you ask your client to touch “contami-
nated” objects.

Guidelines for Setting Up Imaginal Exposures

Use the following strategies to create optimally effective imaginal exposures:
• Use present tense. Ask your client to write the imaginal exposure script using
the present tense. This will have the most powerful impact when the client is
reading or listening to it.
• Include all five senses. Have your client include as many senses as possible in
the imaginal exposure script. For example, if your client has PTSD as a result of
a motor vehicle accident, you should encourage him to thoroughly describe the
sights (e.g., people rushing over to help, big red fire trucks in the distance), the
smells (e.g., smoke, gasoline), the sensations (e.g., fear, heart racing, sweating),
the sounds (e.g., hearing the ambulance sirens), and the tastes (e.g., salty blood
in the mouth).
• Include thoughts and feelings. In addition to involving all five senses, have the
client include details about the emotions, physiological sensations, and thoughts
that he is experiencing. In our example of a client with PTSD from a motor
vehicle accident, include physiological sensations such as pain or dizziness, emo-
tions such as fear, and thoughts such as I’m going to die.
• Include all the scary parts. Clients may skirt around the hardest parts of the
story. Ask your client up front to write down the things that would be hardest to
include in a story, or the parts of the story that he would be most afraid to hear.
Once the list is created, you can say, “What do you think is best for beating your
fear? Should we leave all these components of the story out, or should we make
sure we include them in our story?” With the psychoeducation you’ve already
provided, your client will usually recognize and understand the importance of
moving forward with the story by including the most difficult aspects.
• Work on the story a few sentences at a time. You can ask your client how he
wants to start off the story and help him think about the general flow of it. He
can write a few sentences and then read it aloud to you, giving you a chance to
help edit it. Sometimes, clients will skip through the scary part, won’t write it in
the present tense, or won’t be very descriptive, which is why we encourage you
to help the client refine the story and pause after every few sentences so that you
General Parameters of Exposure 31

have a chance to look it over. It can be helpful to sit at a computer together and
do this, which makes editing easier.
• Don’t wrap up the story on a nice note. If a client has a fear of flying, for
example, you should encourage him to end the story as the plane is going down,
rather than as the plane is landing smoothly on the runway, to best target the
fear.

Exposure to Thoughts
Exposure to thoughts can be very helpful for individuals with intrusive obsessions.
Just as with in vivo or imaginal exposure, in which we ask a client to face feared objects,
situations, or activities, we want our clients to confront feared thoughts (as opposed to
avoiding them).

Examples of Exposure to Thoughts

Consider a client who has upsetting and repetitive thoughts such as I have undiag-
nosed cancer. The client will often try to push these thoughts out of his head or try to
reassure himself that he really does not have cancer. The goal of this exposure exercise
would be to repeatedly think, write, or say aloud the scariest thoughts (e.g., I will die of
cancer) in order to confront the fear and ultimately reduce distress in the long term.
Some other examples of exposure to thoughts include:
• Deliberately thinking blasphemous, “sinful,” or personally repugnant thoughts
• Deliberately thinking of “bad” words, mental images, phrases, or numbers

Guidelines for Setting up Exposures to Thoughts

Generate a list of feared phrases or sentences that your client finds anxiety provok-
ing. Some clients will initially be hesitant to share all of their scary thoughts with you, so
ask follow-up questions, such as “Is that the scariest thought, or is there an even scarier
thought than the one you just mentioned?” Once you have this list, you can ask the
client to choose a feared sentence, such as “I have undetected cancer and will die,” and
to think about or repeat this phrase aloud. To make exposure to thoughts even more
challenging later on, consider pairing these exposures with images you can find online,
such as a photograph of someone who looks sick or a picture of a gravestone.
Here is an example of how to begin an exposure to feared thoughts. In this case, the
client is dealing with uncomfortable thoughts related to illness anxiety disorder.

Therapist: You’ve mentioned that you’ve really been struggling with some scary
thoughts related to having an undiagnosed medical condition, like cancer.

Client: Yes, I have been concerned that this red mark on my arm is the beginning of
skin cancer. I just noticed it last week and it has been on my mind nonstop.
32 The Big Book of Exposures

Therapist: What do you do when these thoughts pop into your mind?

Client: I try to reassure myself that I do not have skin cancer and that everything
is fine. I often ask my spouse if I am okay, or I will look up what skin cancer
looks like online. I sometimes do this for hours. I hate thinking these
thoughts and want to stop having them.

Therapist: Let’s try something, just for an experiment. For a couple of minutes, I’d like
you to try not to think about elephants. Okay? I’ll time you. Whatever
happens, don’t think about elephants. (Two minutes pass.) Okay, what did
you notice?

Client: I tried not to think about elephants. I tried going over my grocery list
instead, to keep my mind occupied. But an image of an elephant kept
popping up in my mind.

Therapist: I’m not surprised. It turns out that none of us is very good at that task. The
reason is that the more we try to push thoughts out of our heads, the more
the thoughts just pop back in. So we have to do the opposite. Instead of
trying not to think these scary thoughts, we are going to face your fears by
writing about, thinking about, and even saying aloud these feared thoughts.
We will do this until the thoughts don’t seem as scary to you anymore.

Exposure to Bodily Sensations (Interoceptive Exposure)

Clients with various anxiety disorders, particularly (but not limited to) panic disor-
der and agoraphobia, often report experiencing uncomfortable physiological sensations.
These sensations can include dizziness, sweating, or racing heart. Often, the client finds
these sensations to be frightening. For example, instead of simply noticing that his heart
is racing, the client may interpret this sensation as a catastrophic event, such as a heart
attack. Just as we would ask a client to approach a feared external stimulus, we ask him
to face feared internal stimuli, a procedure known as interoceptive exposure.

Examples of Interoceptive Exposure

Interoceptive exposure can be a key component of treatment, certainly for clients
with panic and agoraphobia, but also for those with other disorders, such as social anxiety
disorder, OCD, or illness anxiety disorder. Some examples of interoceptive exposures
include:
• Experiencing dizziness by shaking one’s head repeatedly from side to side, spin-
ning in a swivel chair, or turning in circles
• Experiencing lightheadedness or paresthesias (tingling sensations often felt in
extremities or in the face) by hyperventilating
General Parameters of Exposure 33

• Experiencing increased heart rate or sweating by running in place or running up

a flight of stairs
• Experiencing difficulty breathing by holding one’s breath, deliberately hyperven-
tilating, or breathing through a cocktail straw
• Experiencing a stomachache by wearing a tight belt around the stomach, or by
maintaining a half-sit-up until abdominal muscles fatigue
• Experiencing feelings of unreality (depersonalization or derealization) by staring
at oneself in a mirror, being in a room with a strobe light, or staring at light
coming through a venetian blind
• Experiencing nausea by smelling a “nausea jar” consisting of spoiled milk or
meat, cigarette butts, or other foul-smelling objects

Guidelines for Setting up Interoceptive Exposures

Designing and implementing interoceptive exposures requires careful design and
implementation. First, provide information to the client about the rationale for engaging
in these anxiety-provoking exercises. If you have a client who has certain medical condi-
tions that could be exacerbated by the exercises, such as asthma, epilepsy, or heart
disease, seek clearance from his medical provider prior to this intervention (refer to
chapter 6 for an example of a medical clearance form).
Here is an example of how to begin interoceptive exposure with a client for the first
time. In this example, the client has panic disorder and agoraphobia.

Therapist: Just as we have discussed ways in which we can start limiting your avoid-
ance of feared situations, such as going into crowded stores or riding the
subway, to help face your fears through exposure, we are going to begin
using another type of exposure, called “interoceptive exposure.” This is just
a fancy way of saying that we will try to bring on those bodily sensations
that you really don’t like and have been trying to avoid.

Client: Yes, I get panicky all the time. I hate these feelings and wish they would go
away. Why do we have to make them happen on purpose?

Therapist: Well, as you have mentioned in the past, you spend a lot of time trying to
push those feelings away, either by distracting yourself or taking medication
to make them go away. We want to practice bringing them on and not doing
anything to make them go away. Just like other types of exposure, the more
we practice, the easier it will become. I will demonstrate all of these exer-
cises for you so that you know exactly what to do.

Client: What if I have a panic attack?

Therapist: The goal of the exposure is not to bring on a panic attack, though it is pos-
sible that one could occur. If it does, it will be a good opportunity for us to
34 The Big Book of Exposures

practice riding out those feelings until they settle down all on their own
without engaging in any safety behaviors.

Some therapists, particularly those with a touch of exposophobia, will “water down”
the interoceptive exposure intervention by taking excessively long breaks between expo-
sures or trying to calm the client using breathing or relaxation strategies after the intero-
ceptive exposure (Deacon, Lickel, Farrell, Kemp, & Hipol, 2013). We recommend against
the use of such “calming” strategies, preferring instead to deliver the interoceptive expo-
sure fairly intensely, which leads to superior reductions in fear (Deacon, Kemp, et al.,
2013). In our practice, we do an exercise, discuss the exercise and its effects with the
client for a minute or less, then start the exercise again. In order to optimize inhibitory
learning (see more about this below), it’s important that the client feel the sensations that
he fears will lead to a heart attack, going “crazy,” and so on, and recognize that these
things don’t happen.
We have included most of our interoceptive exposure ideas in chapter 6 of this book,
as you are most likely to use interoceptive exposures with clients with panic and agora-
phobia. However, these exercises can be used with any of the anxiety and related disor-
ders in which the client is fearful of his own body sensations. Here is a typical progression
of a first session of interoceptive exposure:
1. Go through the list of interoceptive exposure ideas, which are located in chapter
6, to see which ones might be most appropriate to target your client’s feared
sensations. Demonstrate to the client how to do the first exercise, such as volun-
tary hyperventilation, and then have him do it once.
2. Ask about the sensations that the client feels as well as the anxiety that he
experienced. Then ask the client to rate the sensations and anxiety (see more on
rating using SUDS below).
3. Go to the second interoceptive exposure, show the client how to do it, and then
have him do it once and rate the sensations and anxiety levels. Continue this
process with the other exposures until the client has attempted each one once.
4. Ask your client which exercise(s) he found most distressing and which ones
didn’t create much anxiety at all (you can let go of those).
5. Return to an exposure that elicited moderately scary sensations as a good start-
ing point. For example, if running in place to create a sensation of a pounding
heart is where you and your client agree to start, then have the client repeat that
until his fear has been reduced or he reports a sense of increased mastery over
the exercise.
6. Move on to the next item on the list.

The goal is for your client to learn that these sensations are tolerable and eventually
lessen in intensity with no catastrophic consequence, thus contradicting his negative
expectancies about harm (more about the principle of expectancy violation later in this
chapter). Do not build in safety behaviors or give excessive reassurance to your client that
General Parameters of Exposure 35

he will be okay, that the anxiety will only last a few minutes, or that you are sure it is safe;
these reassurances will weaken the exercises and make it less likely that the client will be
able to do them on his own later without you present. Refrain, as much as possible, from
stopping the exercise early due to the client’s anxiety. Assign these exercises for home-
work so that the client can practice them without having you as a safety net. We recom-
mend that you hold off on assigning new interoceptive exposure exercises for homework
until after the client has practiced them with you in session.

Exposures Using Virtual Reality

Virtual reality exposure therapy (VRET) is another way to help clients face and
work though their fears. This approach has documented efficacy (Parsons & Rizzo,
2008). A meta-analysis of virtual reality exposure in anxiety disorders found that clients
prefer VRET over some kinds of traditional in vivo exposure (Powers & Emmelkamp,
2008).

Examples of Virtual Reality Exposures

Virtual reality exposures can be used for situations in which in vivo exposure is not
possible. Some examples of VRET include:
• Simulated flights on an airplane
• Simulated speeches in front of an audience
• Simulated high places, such as walking across a bridge
• Simulated thunderstorms
• Simulated scenes from Iraq, Afghanistan, Vietnam, or 9/11

Guidelines for Setting Up Virtual Reality Exposures

VRET does not have to be solely used for hierarchy items that cannot be recreated
in session (e.g., a storm). It can also be a lower-level exposure for a client in the same way
that you would use pictures of feared outcomes or online videos to help the client prior
to an in vivo exposure; this is just a more realistic option. It may be very costly to have
clients take repeated airplane flights to work on their fear of flying. However, through
VRET, clients can take several “flights” in a row, and to make it different each time,
several variables can be changed, such as the weather, time sitting on the runway, turbu-
lence, and even whether or not they are sitting next to someone in the airplane. The
graphics on many of the virtual reality devices are pretty remarkable and have come a
long way since their inception.
While some good virtual reality (VR) equipment is very expensive, there are other
more affordable options as well. Newer technology includes I AM Cardboard and the
more advanced Google Daydream View (just one option of many), which is a headset
36 The Big Book of Exposures

that can be used with a variety of cell phones by downloading specific apps. Clients with
a fear of spiders can see creepy, crawly spiders in front of them, and those with a fear of
heights will have the opportunity to feel as though they are at the top of a skyscraper
looking down below. You also have the option in many cases to purchase a controller so
that the client can move around within the VR world. Some VR equipment can be pur-
chased for under thirty dollars, giving you the opportunity to test it out and see if you
want to purchase more advanced packages later on if you find yourself using it often with
clients.

CREATING AN EXPOSURE HIERARCHY

The first step in exposure therapy is to develop a list of exposure activities to be per-
formed. We refer to this as an exposure hierarchy. Collaboratively with the client, we
develop a list of objects, activities, situations, thoughts, or feelings that are not objectively
dangerous but are nevertheless feared and avoided.
The subjective units of distress scale (SUDS; Wolpe, 1990) is a quick and easy way
to obtain your client’s anxiety ratings for the various exposures on his hierarchy of fears.
The SUDS can be used as either a 0–100 or 0–10 scale (whichever you or your client
prefer). It can be useful to give “anchors” to your clients to help them understand how to
use the verbal rating scale. In other words, a “100” rating would be equal to what the
client imagines is the worst anxiety he could experience, or a worst-case scenario. A “50”
rating would be equal to experiencing significant levels of anxiety but being able to con-
tinue in the situation without leaving. A rating of “0” would be no anxiety at all.
For each item on the exposure hierarchy, we assign a value on the SUDS scale. We
ask the client to rate, for each item, how uncomfortable he would be to confront each
object, activity, situation, thought, or feeling. Here is a sample script of what the conver-
sation might be like with your client:

Therapist: What I’d like to do now is start to brainstorm a list of the things that would
be frightening to you. Let’s think about things that you’d rather avoid and
that seem to set off your fears. What comes to mind for you?

Client: Well, I’m afraid to go on an elevator. I use the stairs whenever I can. I’m
really afraid the elevator’s going to get stuck.

Therapist: Okay, so riding an elevator would be scary to you. I’d like to get a sense of
just how scary that would be. Let’s use a number scale that goes from 0 to
100, where 0 is not scary at all and 100 is the scariest thing you’ve ever
done, or could even imagine doing. Where would riding an elevator rank on
this scale?

Client: I think it would depend on whether there was someone else on the elevator
with me. If someone else is there it’s not quite as bad.
General Parameters of Exposure 37

Therapist: Ah, I see. That’s an important distinction, so I’m glad you brought it up. So
let’s look at it both ways. What would your number be if you were to ride an
elevator that had other people in it?

Client: I think that would be about a 60.

Therapist: Okay. Let’s call that your fear level. So your fear level for riding an elevator
with other people would be 60. What about doing the same thing, but by
yourself?

Client: That would be a lot scarier. Because I’d worry that I wouldn’t be able to
escape if it were just me.

Therapist: Can you put a number to that fear, between 0 and 100?

Client: That would be about a 90.

Therapist: Okay, so really scary. What else can you think of?

Client: I don’t like wearing tight clothes, like turtlenecks, that make me feel like I
can’t breathe.

Therapist: Okay, wearing a tight turtleneck would be scary. How scary, on that 0 to
100 scale?

Client: That’s about a 30, I guess.

Therapist: Okay, less scary for that one. Let me run some additional scenarios by you.
What would it be like for you to be in a very small space, like a small closet?

Client: That would be really scary, but why would I do that? I don’t need to be
closed in a small closet in my daily life.

Therapist: Just as an exposure exercise, to help you overcome your fear.

Client: I think that would be really scary, like a 95. I don’t think I can do that.

Therapist: Understood. For now, we’re just coming up with ideas. I suspect that if we
start with things that are a bit easier, after a while you’ll feel stronger and
more able to tackle some of the harder things.

The therapist and client continue this discussion until they have exhausted the list
of possible exposure exercises, as shown in Table 1 (you can find a blank version at the
end of this chapter). As you can see in table 1, the client’s fear is broken down into several
concrete steps and ranked according to the SUDS level.
38 The Big Book of Exposures

TABLE 1. Sample exposure hierarchy

Exposure Hierarchy for My Fear: Enclosed spaces

Activity SUDS (0–100)
1. Flying in an airplane 100
2. Getting into the trunk of a car 100
3. Being enclosed in a small, dark closet 95
4. Riding an elevator by myself 90
5. Being rolled up in a carpet 75
6. Riding an elevator with others 60
7. Sitting in the back seat of a two-door car 55
8. Wearing a face mask 50
9. Sitting in a crowded movie theater 45
10. Being in a hot, stuffy room 40
11. Wearing a tight turtleneck 30
12. Wearing a tight jacket 25

Notice that the exposure hierarchy includes high-fear exposures that are not neces-
sarily considered part of “normal” daily activity. The client noted, quite rightly, that
there was no objective need to be enclosed in a small closet as part of daily living. The
therapist pointed out (as discussed in chapter 1) that the aim of exposure therapy is not
to mimic normal behavior, but rather to develop specific exercises that are designed to
break through the fear. An important rule of the exposure hierarchy is that you should
include the scariest exposures, even if the client doesn’t feel able to do them right now.

ONGOING ASSESSMENT USING SUDS

An important part of your work with your client is ongoing assessment. By assessing our
clients carefully and repeatedly, we can determine whether they are getting better, getting
worse, or staying the same. While there are many assessments that you may use to deter-
mine treatment progress, such as diagnosis-specific measures or more global measures of
well-being, one of the simplest and most individualized ways to capture client progress is
through the exposure hierarchy that the two of you have created. You can have your
General Parameters of Exposure 39

client rerate the exposures listed on the hierarchy at midtreatment and again at post-
treatment (it may even be helpful to do this more often). Table 2 is an example of a
hierarchy created with a client who has a fear of dogs. This hierarchy shows that while
substantial progress has been made, there are a couple of items left to target at the top of
the hierarchy.

TABLE 2. Fear of dogs hierarchy

Exposure Session 1 Session 4 Session 8

Letting a large dog lick my face 100 80 35
Petting several dogs in an enclosed space 95 65 40
(e.g., dog park)
Writing a story about being attacked by 80 50 15
a big dog
Petting a large dog off leash 75 50 20
Visiting a dog park but not going inside 60 30 10
the fenced-in area
Petting a small dog off leash 50 20 15
Petting a small dog on leash 40 10 0

We do not recommend that you let your clients review or see their hierarchy ratings
prior to the rerating as that could influence their ratings, so read each item aloud and ask
the client for the SUDS rating and then put it into the rating sheet you have created.
Clients usually enjoy seeing their progress, so you can chart their progress in a computer-
ized document and give them a printout at posttreatment while you are reviewing their
outcome in treatment. Clients are often surprised to see how high their ratings were at
session 1 since so many of the exposure items are no longer problematic for them!

HOW MUCH FEAR ARE WE AIMING FOR?

In any given exposure session, the goal is not to torture the client and make him experi-
ence sheer terror. Doing so is not only likely to be unproductive, but it also exposes the
client to an unnecessary level of discomfort and increases the risk of noncompliance or
dropout. On the other hand, if fear is too low during exposures, the client doesn’t get a
chance to benefit from the inhibitory learning (more on that in a bit) that occurs during
40 The Big Book of Exposures

exposure: the brain adjusting to new facts about the feared stimulus. Our preference is to
have exposures be challenging but manageable: scary enough that new learning can take
place, but not so scary that the client feels out of control. So, if the client’s SUDS level is
quite low, that’s a sign that you have started too low on the exposure hierarchy and you
should try a higher-ranked item. On the other hand, if the client’s fear level is extremely
high, that’s a sign that you may have started too high and you need to start with some-
thing easier. In this manner, the client’s fear level serves as a guide, allowing you to keep
exposures in the “challenging but manageable” zone.

HABITUATION IN EXPOSURE: IS IT NEEDED?

Aiming for habituation within a therapy session may not be as important as was once
thought. Previously, it was thought that the goal of each exposure therapy session should
be to promote habituation, or a decrease in subjective distress (see Foa & Kozak, 1986).
As an example, clients would be encouraged to continue engaging in the exposure until
their SUDS levels decreased by at least 50%. For instance, if a client had an initial rating
of 80, then he would continue to do the exposure again and again and again until report-
ing a rating of 40 or less. It has been established that habituation experienced during the
session, called within-session habituation, is not a good predictor of outcome (Craske et al.,
2008)—that is, even clients whose SUDS levels don’t decrease significantly during the
session may still have a good response to the treatment. Of much greater importance is
between-session habituation: the degree to which a given exposure becomes easier the next
time the client tries it. Therefore, we de-emphasize within-session habituation here and
talk more about watching for improvement across sessions.

HOW LONG SHOULD EXPOSURES BE?

As noted previously, earlier versions of exposure therapy were based on the principle of
within-session habituation. It was therefore believed that exposures must be prolonged,
in order to allow fear to subside considerably before terminating the exposure. Indeed,
early research with analogue subjects suggested that brief exposures were less effective
than were longer exposures; some were also concerned that short exposures could actu-
ally make the problem worse by sensitizing the client to the feared stimulus (Chaplin &
Levine, 1981; Stone & Borkovec, 1975). Studies with clients who have anxiety-related
disorders, however, have not provided strong support for these ideas (see Craske et al.,
2008). In fact, research suggests that exposure therapy might be effective even when
exposures are short (e.g., Nacasch et al., 2015). In light of this research, we do not rigidly
insist that all exposures be particularly long. As a rough guide, we tend to look for some
evidence that inhibitory learning is taking place—a decrease in reported fear, or some
degree of cognitive change (e.g., increased statements of self-efficacy)—before terminat-
ing the exposure.
General Parameters of Exposure 41

COPING DURING EXPOSURE

Recall from our discussion of exposophobia (chapter 1) that extensive coping skill train-
ing is not always necessary during exposure therapy. Though some clients (e.g., those
with recurrent self-injurious behavior or other particular hazards) might benefit from
emotional coping skill training prior to exposure, we find that most of our clients do not.

Does Relaxation Help or Hurt?

It used to be thought that exposure was most effective when paired with a relaxation
exercise that reduced physiological arousal. That form of exposure, called systematic
desensitization (Wolpe, 1961), was based on the notion of “counterconditioning”: whereas
the feared stimulus is currently associated with a feared consequence, by associating it
with relaxation, we can create a new association between the feared stimulus and a pleas-
ant sensation. However, subsequent dismantling studies (e.g., Agras et al., 1971) demon-
strated that the relaxation didn’t add to the effects of exposure by itself. That is, exposure
without relaxation appears to be just as effective as exposure with relaxation. In fact, in
some cases (for example, clients with panic disorder), it may be that relaxation training
even detracts from the effects of exposure: when clients were randomized to receive
interoceptive and in vivo exposure, with or without a relaxing breathing training, those
receiving exposure alone actually did better than did those who received exposure plus
the breathing training (Schmidt et al., 2000).
How could relaxation detract from the effects of exposure, at least in the case of
panic disorder? One possibility is that the relaxation exercise came to be used as a safety
behavior. As we discussed in chapter 1, safety behaviors are those behaviors, often subtle,
that make the person feel better or safer but undermine the effects of exposure by teach-
ing a lesson of conditional safety (Otto et al., 2011): “I’m safe if…I do my relaxation exer-
cise.” We ultimately want to teach the client a lesson of unconditional safety in which he
understands “I’m safe” without the “if.”

Do Short-Acting Medications Help or Hurt?

A parallel process may occur with the use of as-needed (or prn) short-acting benzo-
diazepine medications. Some evidence suggests that clients with panic disorder who take
prn medications along with exposure fare less well than do clients who receive exposure
alone, or who take the same medications but on a fixed dose (Westra, Stewart, & Conrad,
2002). Our theory is that the prn medication in that study taught the conditional safety
message “I’m safe if…I take my pills,” which undermined the desired unconditional safety
lesson “I’m safe.” In one study, clients with claustrophobia received exposure therapy
along with a placebo pill. Some of the clients were told that the pill was a sedating drug
that would make exposure easier; others were told either that the drug would make expo-
sure more difficult or that it was a placebo. Although all clients did comparably well with
exposure therapy in the short term, at a one-week follow-up, over a third of the group
42 The Big Book of Exposures

who believed they were taking a drug that would make exposure easier showed a return
of their fear, compared with 0% of clients who knew they were taking a placebo (Powers,
Smits, Whitley, Bystritsky, & Telch, 2008).
Conversely, exposure therapy seems to work best when there is significant activation
of fear, rather than deactivation of fear. In one illustrative study of clients with PTSD who
received imaginal exposure, those who exhibited more facial expression of fear benefited
more from the treatment than did those who exhibited less fear (Foa, Riggs, Massie, &
Yarczower, 1995). Similarly, among clients with claustrophobia, higher heart rate at the
beginning of exposures predicted better outcomes of exposure therapy (Alpers & Sell,
2008). Though not all studies have replicated this result (e.g., Meuret, Seidel, Rosenfield,
Hofmann, & Rosenfield, 2012; van Minnen & Hagenaars, 2002), our general sense is
that clients must experience at least some degree of within-session fear activation in
order for exposure therapy to be successful. In support of that notion, it has been demon-
strated that when exposure therapy is combined with drugs that increase sympathetic
nervous system activity (i.e., create more feelings of anxiety and tension), it produces
better effects than when exposure therapy is combined with placebo or with drugs that
decrease sympathetic nervous system activity (Berman & Dudai, 2001; Cain, Blouin, &
Barad, 2003).

The Art of Doing Nothing

So how do we coach our clients to cope with their distress during exposure therapy,
given the fact that (for the average client) relaxing exercises and medications seem to be
ineffective at best, and counterproductive at worst? We favor teaching clients the art of
doing nothing. Individuals with anxiety disorders often overemphasize the deleterious
effects of feeling fear: they worry that if they become very anxious then they will have a
heart attack, go crazy, or just feel bad forever. We want to demonstrate, through experi-
ence, that this is not true. We therefore emphasize distress tolerance as an important skill
to practice (Craske et al., 2008): in essence, coping with anxiety by not doing anything.
By doing nothing in the face of anxiety, the client learns, I can experience anxiety without
it being the end of the world, and I don’t necessarily have to try to make myself feel better.

USING THE INHIBITORY LEARNING APPROACH

IN EXPOSURE WORK
In recent years, exposure therapy researchers have emphasized the principles of inhibi-
tory learning (Craske et al., 2008; Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).
In many anxiety-related disorders, fear is based on associations between a conditioned
stimulus (CS) and an unconditioned stimulus (US). For example, the sight of a dog could
be a CS (the stimulus the person is reacting to), and a painful bite from a dog could be a
US (the consequence that the person fears will occur—whether or not it has ever actu-
ally happened to the client). Learned fear, such as that seen in anxiety-related disorders,
General Parameters of Exposure 43

is present when the person’s reaction to the CS is similar to his reaction to the US. In this
case, the person’s reaction to a dog (fear) is similar to how he would react to a bite. The
brain has learned to associate the CS and US, and they have come to elicit a similar
response. We see this in many of our clients:
• A client with a fear of flying reacts to air travel (CS) with fear, as if it were a
plane crash (US).
• A client with social phobia reacts to benign social situations (CS) with fear, as
if they were humiliations (US).
• A client with OCD reacts to a public restroom (CS) with fear, as if it were
covered with deadly germs (US).

So in each case, what we see is that learning has taken place: our clients have learned
to respond to a relatively benign stimulus as if it were something truly dangerous or
threatening. During the course of exposure therapy, the CS is presented repeatedly
without the US (we call this a CS-noUS pairing). In the case of a dog fear, as just one
example, we present the dog without the bite. Over the course of exposure, the fear
response is extinguished: The person no longer “confuses” dogs with bites and can respond
to a friendly dog without feelings of fear.
What’s happening during this process, at a neurobiological level, is that the prefron-
tal cortical (PFC) regions of the brain start to inhibit regions of the limbic system such as
the amygdala (Delgado, Nearing, Ledoux, & Phelps, 2008). Though the initial CS-US
pairing isn’t necessarily eliminated from long-term memory, these new CS-noUS associa-
tions become the dominant response—a process known as inhibitory learning. It’s called
“inhibitory” because one process in the brain is inhibiting another. Our job as therapists
is to get the PFC regions to be as active as possible, so that we maximize CS-noUS learn-
ing. Below, we will discuss several of these strategies that may help clients develop and
retrieve nonthreat associations.

Maximizing Expectancy Violation

Rescorla and Wagner’s (1972) learning theory suggests that the success of extinction
is the result of a mismatch between clients’ expectations about what they believe will
happen and what they actually experience. Our job as therapists is to maximize the cli-
ent’s experience of “surprise” during an exposure. We can do this by ensuring that expo-
sures are long enough to violate the expectancy. Earlier theorists (e.g., Foa & Kozak,
1986) recommended long exposures to allow sufficient time for within-session habitua-
tion—that is, long enough for the client’s anxiety to diminish significantly during the
exposure. However, as noted by Craske et al. (2008), clinical research raises questions
about the necessity of long exposures and within-session habituation for fear reduction.
In one study, the length of exposure did not seem to matter, as long as there was suffi-
cient time for expectancy violation—that is, as long as the exposure was long enough for
the client to be surprised (Baker et al., 2010).
44 The Big Book of Exposures

In the following example, the therapist seeks to maximize expectancy violation by

focusing on surprises and cognitive change. The therapist and client (who has panic
disorder) have just completed an interoceptive exposure exercise involving running in
place.

Therapist: Okay, we’ve been running for one minute. Let’s pause now. What physical
sensations are you noticing?

Client: Well, I definitely notice that my heart is racing, and I feel shortness of
breath. And I feel a little sweaty.

Therapist: And how similar are these feelings to what you experience when you’re
panicky? Let’s use a scale from 0 to 10, where 0 is not at all like what you
experience, and 10 is exactly what you experience.

Client: It’s definitely similar; I’d say an 8.

Therapist: Okay. And what’s your SUDS level? That’s our 0 to 100 scale of how scary
it is.

Client: I’d say about a 70.

Therapist: Okay, so pretty scary. Did your brain tell you something scary about this
exercise? Like that something bad was going to happen?

Client: Yeah, it told me I was going to have a panic attack and freak out.

Therapist: It does that a lot, doesn’t it? Let’s just experience these sensations for a
moment and pay attention to what happens. What, if anything, surprised
you about this exercise?

Client: I guess I was mostly surprised by the fact that I didn’t panic.

Therapist: So what’s the lesson learned here? What information do you want your
brain to absorb?

Client: That just because my heart’s racing, that doesn’t mean I’m going to panic.

Therapist: Exactly. You’re teaching your brain that your heart can race, and that
doesn’t have to be a big deal. You did a really nice job with that exercise.
Let’s keep it up!

Limiting Distraction
It is important for the client to limit the use of distraction during exposure therapy.
Research generally suggests that it is more beneficial to be focused on the exercise or
exposure, including paying attention to the feared situation and the feeling of fear in the
General Parameters of Exposure 45

body, as opposed to trying to distract from it (Grayson, Foa, & Steketee, 1982; Kamphuis
& Telch, 2000; Telch et al., 2004). Distraction can have several negative effects on expo-
sure. First, it breaks up the exposure, so that instead of one long exposure session, the
client is actually experiencing several briefer exposure sessions (which are potentially not
long enough to violate expectancies, as discussed above), punctuated by periods of dis-
tracted attention. Second, distraction impairs the client’s ability to recognize that the
disaster is not occurring in the presence of the feared situation or stimulus. You need to
be on the lookout for distraction in your clients and need to help bring them back to the
exposure if they start to go off course. In this example, the therapist is working with a
client who has a fear of elevators.

Therapist: Okay, we are on the elevator and are going to continue to ride it up and
down the ten floors like we previously agreed, to target your fear of getting
stuck. I want you to focus on what you see in the elevator and how you feel
without engaging in any distractions.

Client: Okay. (A few moments go by.) I forgot to tell you earlier that I had difficulty
with some of the therapy homework you gave me last week and I have some
questions about it.

Therapist: We can definitely address this following the exposure. Right now, I would
like you to try to stick with this exposure without thinking about other
things since it is considered distraction. To come back into the exposure,
think about the way the elevator feels moving up and down, what the
buttons look like, how your heart is racing, and so on. Let’s stand quietly for
the rest of the ride.

Fear-Antagonistic Actions
It can be useful to encourage the client to engage in fear-antagonistic actions—that is,
behaving as if he is unafraid (Weisman & Rodebaugh, 2018). Research demonstrates
that exposure therapy is more effective when clients are instructed to engage in “brave”
behaviors, such as running toward the balcony for those with fear of heights (Wolitzky &
Telch, 2009) or deliberately stuttering during a speech for those with public speaking
fears (Nelson, Deacon, Lickel, & Sy, 2010). These actions serve to maximize the mis-
match between expectancies (for example, stuttering during a speech and everyone
laughing and pointing at him) and outcomes (stuttering on purpose during a speech and
the audience not reacting poorly). In this example, the therapist is working with a client
who has a fear of heights, and they are standing on a high balcony together.

Therapist: You’re doing a great job with this exposure. I’m really impressed that you got
up here.

Client: Yeah, I feel like it’s getting easier the more time we spend up here.
46 The Big Book of Exposures

Therapist: I wonder whether we could up the ante a little bit. Right now I notice that
you’re backed away from the railing and are being very still.

Client: That’s true; I am. I guess I’m still feeling kind of nervous.

Therapist: That’s completely understandable. But what I’d like to have you do is act as
if you were completely unafraid. Let’s think about that for a moment. If you
were completely unafraid, what would you be doing up here?

Client: Um, I guess I’d be closer to the railing?

Therapist: Yes, probably. How would you get to the railing, if you were completely
unafraid? Would you tiptoe toward it?

Client: No, I guess I would just walk up to it.

Therapist: I wonder whether we could even take that a little further and have you walk
very quickly toward the railing?

Client: That would be really scary. I’d worry that I would fall over.

Therapist: Yes, I could imagine that’s what your brain would be telling you. But perhaps
we don’t need to listen to that part of your brain right now. Perhaps we
could just act completely unafraid and walk really briskly over to the railing,
like this (demonstrates). Now can you try that?

Client: I guess I can try. (Client walks briskly to the railing.)

Therapist: Great job. Now let’s really act unafraid. Can we run over toward the railing,
like this (demonstrates)?

Client: Wow, that just seems really scary. I think if I did that, I would fall right over.

Therapist: You think you wouldn’t be able to stop. But is that really true? Has anything
like that ever actually happened to you?

Client: No, I guess not.

Therapist: No. That’s just your brain trying to talk you out of this. But let’s show your
fear who’s boss by running right up to the railing.

Client: Okay, I can try it.

Deepened Extinction
The concept of “deepened extinction” (Rescorla, 2006) refers to the simultaneous
presentation of multiple CSs, which have previously been extinguished in isolation or
though one part of the hierarchy at a time. When multiple feared stimuli are presented
General Parameters of Exposure 47

at the same time (“piled on”), we maximize the client’s ability to be surprised by the
outcome. For example, if a client has PTSD from being mugged in an alleyway, you may
have helped him do various exposures to target this fear, such as reading stories of others
who were mugged, going to new alleyways, and eventually going back to the scene of the
incident. When you are piling on stimuli at the same time (usually in later therapy ses-
sions), you may ask the client to visit the alleyway while also reading aloud a story about
being mugged.
Here, the therapist is working with a client who has panic disorder and agoraphobia.
In previous sessions, they have conducted interoceptive exposures, including hyperventi-
lating and spinning. Today, the therapist and client are meeting in a crowded shopping
mall and have spent some time walking through the crowd.

Therapist: You’ve done a nice job tolerating the distress of being here in the mall. I can
see that you feel a little more comfortable with it.

Client: Yeah, I feel okay. It’s still kind of scary, but I’m handling it a bit.

Therapist: What I’d like to do now is combine this exposure—walking through the
mall—with an exposure that we’ve already done. Do you remember a couple
of weeks ago when we practiced hyperventilating in my office?

Client: Yeah, I got really lightheaded and nauseated.

Therapist: Yes, and then you started to feel less fearful, right?

Client: Yes, I did.

Therapist: So what I’d like to do now is have you hyperventilate here in the mall.
Here’s my thinking behind that: Right now, you’re doing a great job tolerat-
ing the distress of being in the mall, and you feel okay physically. What we
need to do next is have you practice tolerating the discomfort of being in
the mall even when you don’t feel okay physically. So I want us to practice
feeling bad in the mall so that your brain starts to learn that’s not a threat
either. Does that make sense?

Client: Yes, I guess so. It’s a scary idea, though.

Therapist: Yes, and that’s all the more reason why we should tackle this fear and make
sure that the mall can’t scare you, even when you don’t feel okay. So can we
do some hyperventilating right here, together?

Client: Okay. (They hyperventilate.)

Therapist: Perfect. What’s your fear level right now?

Client: About an 80. It’s scary.

Therapist: Okay, so let’s just walk around now and see how this feels.
48 The Big Book of Exposures

Eliminating Safety Behaviors

Safety behaviors are subtle (and sometimes not so subtle) things that the client does
to feel safer. The most obvious example of safety behaviors are compulsions (e.g., hand
washing, ordering, checking) exhibited by clients with OCD, though safety behaviors
can be seen in any of the anxiety and related disorders. When safety behaviors are used
during an exposure (for example, a client with OCD washing his hands, a client with
panic disorder carrying an anxiolytic medication, or a client with social anxiety standing
in an empty corner at a party), the nonoccurrence of the US is attributed not to the
unconditional safety of the situation, but to the conditional safety of the behavior. In other
words, safety behaviors contribute to learning things like “I’m safe if…I wash my hands
when they appear dirty.”
Several studies show that exposure efficacy is improved when anxious clients are
discouraged from engaging in safety behaviors (Hedtke, Kendall, & Tiwari, 2009; Kim,
2005; Powers, Smits, & Telch, 2004; Sloan & Telch, 2002). Conversely, some analogue
(student) samples have failed to replicate this finding (Deacon, Sy, Lickel, & Nelson,
2010; Levy & Radomsky, 2014; Rachman, Shafran, Radomsky, & Zysk, 2011). Our
opinion, based on all of the available data, is that safety behaviors are often (though not
always) detrimental to the process of exposure therapy, and there is little evidence to
suggest that they are helpful (at least in clients with anxiety disorders).
In this example, the therapist is coaching a client with panic disorder on a home-
work assignment to ride a city bus.

Therapist: One thing that’s really important is to get rid of all of those things, big or
little, that you do to try to feel better, or that you think might be keeping
you safe. What kinds of things can you envision having with you on the bus
that would fit that description?

Client: Definitely my bottle of pills. I don’t even take them that much, but just
having the bottle makes me feel a lot better.

Therapist: Understood. The problem we run into is that anxiety is really good at saying
“I’m safe if…” and then putting all of these rules around what’s safe and
what’s not safe. And of course, the problem is that one of these days you’re
going to find yourself in a tight situation without your pills, and your brain
won’t have learned that that situation is safe, too. Does that make sense?

Client: Yes, I understand that, but it’s a lot scarier to ride the bus if I don’t have my
pills with me.

Therapist: It makes sense that that would be scarier for you. You’ve relied on these pills
for a long time, like a crutch. But we know that exposure therapy is going to
work a lot better for you if you don’t bring your crutch with you.

Client: So I should leave my pills at home when I ride the bus.

Therapist: Exactly.
General Parameters of Exposure 49

Occasional Reinforced Extinction

Occasional reinforced extinction refers to occasionally allowing the CS and US to
be paired during exposure (Woods & Bouton, 2007). This may seem clinically counter-
intuitive, as we generally think that exposure works when the CS is presented repeatedly
in the absence of the US. However, it can sometimes be helpful to arrange for the “disas-
ter” to occur during exposure. Our experience has been that exposure to certain “disas-
ters,” when handled carefully, can serve to diminish the threat value of the US, which
can teach the client that even if the “disaster” occurs, the results are not necessarily cata-
strophic. For example, for the client with social anxiety disorder who fears making audi-
ence members bored during a presentation, you may set up an audience of confederates
(e.g., trainees or colleagues) and ask some of them to scroll through their phones, yawn,
or even leave the presentation early. This will set up the “disaster” for the client in order
to help him get through the worst-case scenario and live through it. Here, the therapist
is working with a client with OCD who has a fear that she will harm others by having
bad thoughts about them.

Therapist: For our next exposure, I wonder whether you could wish for me to develop
a brain tumor.

Client: That’s scary, but I can try.

Therapist: Okay, so wish for that out loud: “I wish for you to get a brain tumor.”

Client: I wish for you to get a brain tumor.

Therapist: What’s your level now?

Client: About a 60.

Therapist: Okay, so that’s not so bad. The next thing I’d like to try is that you wish for
me to get a brain tumor, but this time I’m going to tell you whether I feel
anything.

Client: Okay. I wish for you to get a brain tumor.

Therapist: I’m feeling a slight headache at the moment.

Client: Yeah, that’s scary.

Therapist: What’s your fear level?

Client: That’s an 80.

Therapist: Okay, let’s stay with this exposure for a bit. You keep wishing for me to get
a brain tumor, and I’ll keep describing my headache to you.
50 The Big Book of Exposures

Changing the Context

Fear can be reinstated after extinction if the context in which the individual encoun-
ters the feared stimulus changes (Mineka, Mystkowski, Hladek, & Rodriguez, 1999); this
phenomenon can be lessened by conducting exposure in multiple contexts (Bouton,
1993). Varying the kind of exposures conducted—for example, exposure to several dif-
ferent kinds of dogs, rather than one kind—is one straightforward way of increasing
variability, thereby reducing the likelihood that fear will return. Another is to change the
conditions under which the client encounters the stimulus. For example, we could vary
the external contexts by conducting exposures in the therapist’s office, outside, and in the
patient’s home or other location, during the day and at night. We could also vary the
internal context by having the patient engage in exposures both when relatively calm and
after fear has been aroused.
In this example, the therapist is working with a client who has panic disorder and
agoraphobia. Having completed a session of interoceptive exposure in the session, the
therapist now assigns in vivo exposure homework.

Therapist: Last week, you went to the mall and walked through the crowds, and you
did a really great job with it. I’m interested in having you do something
similar, but changing the context a bit. Are there some other really crowded
places you could go to besides the mall?

Client: Hmm. I guess maybe a sporting event of some kind? I used to like to go to
ball games, but I stopped going because of the crowds.

Therapist: That’s a really good idea. What would you think of trying to get to a ball
game this week?

CONCLUSIONS
In this chapter, we have reviewed the various types of exposures that can be useful in
helping your clients face their fears: in vivo exposure, imaginal exposure, exposure to
thoughts, interoceptive exposure, and using virtual reality in exposure. Exposure therapy
is partly about what we ask the client to do, but it is also partly about what we ask the
client not to do. We discussed some inhibitory learning principles as well as strategies to
help clients to extinguish the association between a feared object, thought, situation, or
sensation and the feared consequence.
In the next chapter, we’ll talk about doing exposure with children and adolescents.
We will teach you how to best work with the parents of your client as your co-therapists.
In addition, we will give you advice on how to make the therapy experience easier to
understand and even more engaging for your younger clients.
General Parameters of Exposure 51

CHAPTER RESOURCES
Reminder: These resources are also available to download and print from http://www.
newharbinger.com/43737.

Exposure Hierarchy for My Fear:

Activity SUDS (0–100)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.
52 The Big Book of Exposures

Interoceptive Exposure: Anxiety Tracking Using Suds

Activity Time 1 Time 2 Time 3

SUDS SUDS SUDS
(0–100) (0–100) (0–100)

Example: Hyperventilating for 60 seconds 70 55 35

 CHAPTER 4

Helping Kids Climb the Exposure Ladder

Now that we have reviewed the rationale for exposure therapy as well as how to effec-
tively design and implement various types of exposures (e.g., in vivo, imaginal, and
interoceptive), this chapter will focus on how to work creatively and effectively with your
younger clients and their parents. As mentioned in chapter 1, clinicians with exposopho-
bia may have a misconception that children won’t do well with exposure therapy.
However, children can do very well with it and can often understand quite quickly why
we are using it—sometimes even better than our adult clients! Many of the same prin-
ciples still apply when conducting exposure with a younger population. That being said,
there are some important tweaks that you can make to the treatment to help better
engage the client: adapting the psychoeducation component; including the parent(s) in
session; using child-friendly strategies such as naming the anxiety, drawing the anxiety
“creature,” playing games, and getting out of the office; and rewarding the behaviors you
would like to see the child continue to do.

PSYCHOEDUCATION WITH CHILDREN

AND ADOLESCENTS
Just as with your adult clients, you want your younger clients to know what to expect in
treatment and to have the opportunity to ask any questions they may have about your
work with them. You are asking your clients to do the very thing they fear. This can
sound scary to your younger clients (just as it can to your adult clients), but it’s all in the
delivery of how you explain exposure therapy to them. Here’s an example of a conversa-
tion you could have with a younger client about what to expect during exposure therapy:

Therapist: I’m so glad that you are going to start doing exposure therapy. We’re going
to work together as teammates during this time to help you feel better and
get your anxiety to stop bossing you around. Does that sound okay to you?

Client: Yes, but what is exposure therapy?

Therapist: Let me give you an example of what therapy will look like. Do you like dogs?

Client: Yes! I love dogs and even have one.

54 The Big Book of Exposures

Therapist: That’s great! I really like dogs too. What you would do to help a friend who
maybe wanted to come over to your house to play but was really scared of
dogs?

Client: I could put the dog in my basement so she wouldn’t be afraid.

Therapist: Do you think that will help your friend learn to like dogs and no longer be
afraid?

Client: Well, no, because she wouldn’t ever see my dog so she wouldn’t get to see
how friendly she is.

Therapist: Exactly. Hiding away or avoiding something scary doesn’t help you get over
your fear. So, let’s think of some other things we could do to help your
friend.

Client: We could show her my neighbors’ dog who is really small and lies around a
lot so there isn’t much to be scared of.

Therapist: Wonderful idea. Then once your friend starts finding it easy to be around
your neighbors’ small dog, you could let your friend meet an even bigger dog.
We might even want to think about things such as starting easy with a dog
on a leash and then later having the dog be off the leash.

Client: Oh, I get it. Yeah, we could even ask my friend to stand far away from the
dog and then get closer to it.

Therapist: Maybe as one of the very last exposures you could have your friend go with
you to a dog park where there are lots of jumpy dogs.

Client: That would be so scary to my friend right now.

Therapist: I bet. So that’s why we start off with the smaller cute puppy and work our
way up the exposure ladder to more challenging exposures. This is what we
are going to do every time you come to my office. I want you to help me
come up with a list of things we can do together to gradually help you with
your anxiety. Think you are up for the challenge?

PARENT-BASED INTERVENTIONS
When doing exposure therapy with children, we often modify treatment to include the
parents as “co-therapists” (Piacentini et al., 2011). Two particularly helpful interventions
are (a) including parents in exposure therapy and (b) helping parents to reduce their
reassurance-giving and other accommodations to their child’s anxiety.
Helping Kids Climb the Exposure Ladder 55

Including Parents in Exposure

It can be beneficial to have the parents see what you are doing with the younger
client so that they can help their child at home and act as effective co-therapists. After
you have provided the parents with psychoeducation about exposure therapy and how it
will be used to treat their child’s anxiety, invite the parents into the room to watch an
exposure session. There are several things you should go over with the parents in session
so that they can continue to help their child at home. These include prompting the child
to do exposure homework, coaching her through the exposure, and praising the child’s
hard work.

Prompting
Younger clients may not remember to work on the problem on their own, or they may
be less intrinsically motivated to change maladaptive behaviors and to face feared situa-
tions than are some adult clients. Therefore, we encourage parents to prompt the child
to do her exposure homework between sessions. It can be helpful for parents to talk with
their child ahead of time (or better yet, in session) to decide what time of day the child is
going to work on exposure. Once a time is set up, the parents should gently remind the
child that it is time to begin homework. If a predetermined time is not scheduled, the
child and parents may be more likely to battle each other over homework. We suggest
having the parents and/or the child set alarms on their smartphones or other devices so
that they are prompted to do the exposure homework. You can ask the family to set their
phone alarms when you are assigning homework for the week.

Coaching
In addition to reminding the child to do the exposure homework, the parents can
coach the child through the exposure homework assignment. Especially earlier in treat-
ment, the parents might have a better handle on exposure, and how to implement it,
than does the child. The parents can remind the child about how to start the exposure,
what safety behaviors to be on the lookout for (and how to eliminate them), and when to
stop the exposure.

Praising
Encourage parents to praise their child for attempting and completing exposure
exercises. The child does not always need to have a reward or treat but can benefit from
the parents’ verbal praise. The parents can say, “Nice work; you really fought hard to do
the opposite of what your anxiety was telling you to do,” “You were so brave,” “That was
really impressive,” and “Keep up the amazing work—I know how hard this is.” As a clini-
cian it can be helpful to watch how the parents praise (or don’t praise) the child in
session. Model for the parent how you praise the child during or following the exposure.
Don’t forget to praise the parents for all of their hard work too!
56 The Big Book of Exposures

Reducing Reassurance-Giving and Other Family

Accommodations
Reducing reassurance and other accommodations is an essential part of CBT for
children and adolescents with anxiety and related disorders. In fact, even if the younger
client refuses treatment and does not set foot into your office, this is a topic that you can
address with the parents, which can trickle down to helping the child in the long run.
One of your first jobs as a therapist tackling an anxiety-related disorder in a younger
client is to determine the degree of family accommodation: the extent to which parents or
other family members have altered their own behavior to adjust for the child’s fear.
Explain to the family that accommodations are things that they do or say to cater to the
child’s fear in an attempt to make the child more comfortable. These accommodations
tend to grow and get out of control over time. For example, the child with OCD may ask
her parents to wash their hands before touching the family computer. The parents may
initially agree to do so, so that the child can continue to use the computer and feel com-
fortable. However, over time the parents may start washing themselves repeatedly before
touching any item in the house in the presence of the child, or even disinfecting objects
within the home.
Accommodations can take many forms. Examples of commonly seen family accom-
modations to the child’s anxiety include the following:
• Parents provide excessive reassurance to the child that things are okay or that
the child will not get hurt, anxious, dirty, or kidnapped.
• Parents refrain from sending the child to needed after-school care while they are
at work, or leave work early due to the child’s separation fears.
• Parents buy extra soap, hand sanitizer, or other household cleaners due to the
child’s concern about contamination.
• Parents change clothes when entering the home to be “clean” and may even
have siblings do the same.
• Parents refrain from using certain words, phrases, or sentences that elicit the
child’s anxiety.

Over time, parents can easily get swept up in giving reassurance and providing
accommodations to their child even when the child isn’t asking for it. For example, if a
child with OCD is practicing touching dirty items in the therapy office, one of the
parents might say, “Don’t worry; that is probably not very dirty and won’t hurt you,” or
“You can shower when you go home tonight.” This is a wonderful opportunity to gently
remind the parents about why such statements, though intended to be caring and helpful,
are contraindicated in treatment. Let them know you don’t expect all of this to change
overnight and that you will work with them to remind them to make fewer reassurance
statements, and give them their own homework to practice during the week as well.
Remember, there is no one to blame here. At the end of the day, the parents are just
trying to make their kids feel better and to have less anxiety. The problem is that the
Helping Kids Climb the Exposure Ladder 57

reassurance-giving and other accommodations, such as those described above, may work
as a short-term fix for the child’s anxiety, but the problem doesn’t get any better in the
long run. Ultimately, the reassurance-giving and excessive accommodations prolong the
child’s anxiety. It is critical to help the parents understand the long-term consequences
of these behaviors and help them learn healthier strategies. Here’s an example of how to
have this conversation with the parents of a child with contamination-based OCD:

Therapist: Now that we’ve talked more in depth about exposure therapy, I wanted to
have a conversation with you about things we can change in order to help
your daughter make the most progress she can in therapy.

Parent: Sure, that sounds great.

Therapist: You’ve mentioned that your daughter asks you questions over and over again
even when you have already answered them; is that right?

Parent: Yes, she repeatedly asks all sorts of questions, such as, “Will I get sick from
using my friend’s pencil at school today?” and the other one we hear all the
time is “Am I going to be okay?”

Therapist: How do you typically handle those questions?

Parent: First, we usually say, “You’re fine; don’t worry about it.”

Therapist: Does that satisfy her and her anxiety?

Parent: Hardly ever anymore. Usually, she doesn’t like the answer and tries to get us
to say something very specific, such as “I promise that you will not get sick.”

Therapist: Are there other accommodations you make to your child’s anxiety?

Parents: Yes. It’s become quite extensive. We feel as though we are constantly cater-
ing to her anxiety. She asks us to remove our work clothes before entering
the house and will never let us enter her room or sit on her bed unless she
is reassured that we are clean. We do more laundry than ever before, because
she goes through so many of her clothes during the week due to her need to
be clean.

Therapist: I see. Have you ever tried cutting back on these accommodations in the
past?

Parent: Yes, and it went horribly. She cried, and begged, and told us we were awful
parents. It was really hard to see and hear.

Therapist: That must have been really hard. What ended up happening after she
pleaded with you?

Parent: Eventually we promised she wouldn’t get sick or be contaminated. We did

everything we could to make her feel better, even though it has been hard
on us time-wise and financially.
58 The Big Book of Exposures

Therapist: Got it. What you did is very understandable. As parents, you want to protect
your child and take away negative feelings. That’s really normal. But, has it
helped your daughter get over her fears of touching dirty things, or allevi-
ated her worries about getting sick?

Parent: No, it’s worse than it’s ever been.

Therapist: Okay, so it sounds like you gave it a good shot to try to eliminate her anxiety
by reassuring her and accommodating the anxiety, but as you say, it hasn’t
helped. In this treatment, we are going to try something different. We are
going to limit and eventually eliminate altogether the reassurance and other
accommodations you are giving your daughter when it comes to her OCD-
related fears.

Parent: That sounds hard.

Therapist: It is hard at first, but like anything else, it gets easier. Your child will also be
prepared that this is coming, and will know why you are being asked to do
this. Since the level of reassurance-seeking is pretty high right now, let’s
start with you being able to answer the question your daughter asks you only
once, and if she asks it again you can say, “I already answered that; remem-
ber what I said before.” Then don’t say anything else.

Parent: Okay, I think we can do that.

Therapist: We will make this increasingly more challenging over time by giving no
reassurance at all and then maybe even giving the opposite of the kind of
reassurance your daughter is seeking. For example, your child may ask,
“Will I get sick?” and I’d encourage you to answer with, “Yes, you’re going to
get sick.” We’ll make sure to give your daughter advance notice that you’ll
be answering questions in this way.

Parent: That sounds so hard!

Therapist: That will come later on in therapy, but I wanted to give you an idea of where
we will be heading. By the time you are asked to do that, it likely will not be
as challenging for you or your daughter as it sounds today, because you will
have already done so many other things. Other examples of assignments I
give you might include only doing one load of laundry per week, or limiting
the soap in the house, or even eliminating it all together for a period of time.

Parent: Okay, we can give it a try.

Therapist: I do want you to keep in mind that the key to this working is being consis-
tent with the assignments I give you related to cutting back on all of the
accommodations related to her OCD. It won’t work as well if you give reas-
surance sometimes, or if you give in when she begs and pleads. Are you up
for committing to doing this consistently to help your daughter?
Helping Kids Climb the Exposure Ladder 59

When Children Refuse Treatment

If you work with children or adolescents, you know that sometimes they refuse treat-
ment even when they are struggling tremendously. This can be challenging for a family
and can leave them confused about the next steps. Fortunately, you can work directly
with the parents to help modify their behaviors, which will ultimately benefit the child.
Parent work alone has been shown to improve outcomes, even when the child is reluctant
to engage in treatment. As one example, the SPACE Program (which stands for
Supportive Parenting for Anxious Childhood Emotions) is a treatment protocol designed
for parents to learn new strategies and help treat child and adolescent anxiety, without
the child’s direct participation with the therapist (Lebowitz, 2013; Lebowitz, Omer,
Hermes, & Scahill, 2014).
The younger client may be upset that you and the parents are continuing in treat-
ment even though she has refused. Have the parents periodically invite their child to join
the therapy and to add her input at any time. It is important that parents keep their child
informed about treatment and what to expect, rather than changing everything up and
withdrawing accommodations without giving any notice to the child.
We have included a worksheet at the end of this chapter for you to keep track of the
family accommodations that are being made for the child’s anxiety. You can share this
worksheet with the parents, and they can add accommodations that need to be elimi-
nated to the worksheet as well. Make sure to assign homework for the parents that
includes reducing these behaviors.

CHILD-FRIENDLY STRATEGIES
When working with children and adolescents with anxiety disorders, it’s important to
incorporate fun ways to engage them in the sessions. This can include playing games,
drawing the anxiety monster, and getting out of the office. We’ll describe child-friend
approaches in greater detail below.

Using Games to Help Kids Learn

Following psychoeducation with the parent(s) and child or adolescent, you can
explore how much your young client has learned about exposure by turning it into a
game. We often ask our adult clients to summarize the treatment back to us, so that we
can gauge their level of understanding and correct any misconceptions. For some of our
younger clients, instead of a back and forth conversation, we’ll play “host” of a “game
show” in which we quiz the child on some of the key psychoeducational points. Invite the
parents to play the game too, to see who can buzz in the fastest and win the most points.
Even if the child is getting some of the answers wrong, she is still learning. The sample
Psychoeducation Game Show Questions and Answers list at the end of the chapter con-
sists of generic questions related to CBT and exposure, but we encourage you to add more
60 The Big Book of Exposures

specific questions related to that child or adolescent’s diagnosis. For example, if the child
has panic disorder, you may want to add questions such as “True or false: Panic attacks
are uncomfortable but harmless.” (True).

Naming the Anxiety

A good way to help your younger client learn to separate herself from the anxiety
and to externalize it is to name it. For example, a client with OCD who lines everything
up perfectly and in order might decide to name the OCD “Mr. Perfect.” Then you (and
the parents) can say to the child, “Is it really true that you want to spend twenty minutes
lining things up just so before going out to the movies, or is that something Mr. Perfect
is telling you to do?” Over time the child will learn that it is the anxiety, Mr. Perfect, who
is bossing her around, telling her what she can and cannot do. This is a nice way to help
the child see that she needs to “boss back” the anxiety (e.g., March & Mulle, 1998) and
to do what she wants to do (e.g., go to the movies on time) without listening to Mr.
Perfect’s instructions.
Sometimes clients will have difficulty coming up with a name on the spot, so give
them some examples of various names and assign naming the anxiety for homework. Ask
your client to think about various characters from books, television shows, or movies to
come up with a name for the anxiety.
Here are some examples of names that might suit your client’s anxiety:
• Mr. Perfect—This is a good example of a name to describe the anxiety of
someone who is very perfectionistic, hates making mistakes and avoids them at
all costs, and tries to do things in exactly the “right way.”
• Mr. Clean—This is a good name for a client whose OCD involves contamina-
tion fears, and who engages in cleaning rituals or tries to avoid coming into
contact with objects, places, or people who are perceived to be dirty.
• Regina George—A character from the movie Mean Girls, Regina George is the
epitome of a high school bully. She is bossy to others, manipulates them, and
acts as though she is superior to those around her.
• Miss Worrywart—This is an example of a name to describe the anxiety of
clients who may be engaged in excessive ruminating, obsessing, or worrying.

Let the younger client explain to her parents why she is naming the anxiety and why
she chose that particular name. Encourage the parents to use the anxiety’s name as well
at home, and give the parents examples of how to use it. For example, if your younger
client has contamination-related OCD and has been having a hard time getting out of
the bathroom in the morning because she is caught up in compulsions, the parents can
say, “Wow, looks like Mr. Clean (or whatever name the child has chosen) has been really
bossy to you and is telling you that you can’t come down for breakfast unless you wash
your hands again. Do you want to let Mr. Clean keep bossing your around, or should we
boss him back?”
Helping Kids Climb the Exposure Ladder 61

Drawing the Anxiety Creature

It can be helpful to encourage the child to draw a picture of the anxiety creature, so
that she can hold the image in her mind of whom exactly she is fighting. This can be a
good homework assignment or something that you do with your younger client in session,
especially if she has been slow to warm up. If a younger child is shy about it at first, you
can give her examples of characteristics to give her anxiety creature, such as a unibrow,
a head of spiky hair, or green teeth. In the final session of therapy, you can make a pho-
tocopy of the child’s anxiety creature and allow the child to rip it up and throw it away,
signifying that she beat the anxiety creature.

Getting Out of the Office

Exposure often involves doing work outside of the confines of the office. Ask the
younger client’s parent(s) to join you in leaving the office space or get permission to do so
one on one with your client, such as going outside or to another floor of the building to
do an exposure. We don’t recommend driving with clients in your car, so when you are
planning an exposure at a separate location (e.g., grocery store, mall), we suggest you
meet the child and parents at the site.

USING REWARDS
It is not always essential to use a reward system during exposure therapy with a child.
Some children will be very motivated to work on the anxiety or other difficulty without
needing any incentives other than verbal praise. However, you may find yourself working
with a younger child who may not fully understand the rationale for exposure and there-
fore is more reluctant. In such cases, consider using a reward chart.
If you decide to use a reward system with your younger client, there are some guide-
lines we suggest you keep in mind.

Refrain from Using Rewards as Bribes

Reward charts should be individualized to the client so that she can be working
toward earning fun activities or things. Rewards need not (and should not) be expensive.
They can include earning extra time on the computer or video game console or getting
to choose where the family is ordering take-out food from that night. You (and the
parents) are not using the reward system as a bribe to get the child to do the exposure,
but rather are rewarding the child’s hard work in fighting back against anxiety and taking
better control of her life. Rewards should be planned ahead of time so that the child or
adolescent knows exactly what she is working toward earning. Bribes, as opposed to
rewards, tend to be more spontaneous in nature. Have this conversation with the
parent(s) about the reward system so that they know how to best implement it at home.
62 The Big Book of Exposures

Create a Rewards Menu

When creating the reward chart, include both short-term rewards that the child
could earn daily and longer-term rewards. For the latter, the child can choose to save up
points and cash them in for a bigger activity or special occasion later on. We have
included a list of ideas for you to consider with both the child and parent(s) when creat-
ing your chart. Brainstorm other ideas in session with both the younger client and
parent(s).

Quick-to-earn prizes
• Skip a chore. Choose a typical chore done at home to skip for the evening (e.g.,
dishes, picking up room).
• Bonus time added to bedtime. Go to bed fifteen (or other predetermined
number) minutes later.
• Extra screen time. Get fifteen (or other predetermined number) extra minutes
of TV time or videogame time.
• Go outside. Go to a nearby park or play a game outside in the yard.

Harder-to-earn prizes
• Sleepover. Have a sleepover with a friend or at a family member’s house.
• Spend the day with a friend. Have a friend over or go to a friend’s house for the
day.
• Get pampered. Get a manicure or pedicure.
• Get a treat. Go out for ice cream or another treat.
• Get a new toy. Pick out a toy or game under $20.
• Get to choose dinner. Choose a dinner restaurant or take-out option for the
family for the night.
• Movie date. Go to a movie theater and choose the movie.
• Do an activity. Go mini-golfing or bowling.

CONCLUSIONS
Exposure treatment for many of the anxiety-related disorders is quite effective with child
and adolescent clients. As we have discussed, there are some nuances of doing successful
exposure work with children and adolescents, including the importance of working with
parents. Having the parents reduce their accommodations to their child’s fear during
exposure work, as well as having them refrain from providing their child with excessive
Helping Kids Climb the Exposure Ladder 63

reassurance, is critical. And by incorporating strategies such as playing games, naming

the anxiety, and setting up rewards (not bribes), you can increase the likelihood that your
younger clients will be motivated to engage in exposures.
Now that you are equipped with how to best design and implement exposures, with
both adults and younger clients, we will start our venture into part 2 of the book, which
dives deep into creative and effective exposure ideas. The chapters in part 2 are dedi-
cated to each of the anxiety and related disorders for which you are most likely to use
exposure as the treatment or as a major component of the treatment.

CHAPTER RESOURCES
Reminder: These resources are also available to download and print from http://www.
newharbinger.com/43737.
64 The Big Book of Exposures

List of Accommodations to Be Eliminated

Accommodation Difficulty level

(1–100)
Example: Giving reassurance that everything will be okay 85
Helping Kids Climb the Exposure Ladder 65

Psychoeducation Game Show Questions and Answers

1. Draw the CBT triangle. (See diagram in chapter 1.)
* Earn an extra point if you draw the arrows correctly.

2. True or false: People are just born with anxiety, and once they have it there is
nothing they can do about it.

3. What does the word “exposure” mean? (Exposure is when you do the thing that
you fear.)

4. True or false: Anxiety is something that is designed to protect you but can go
off at the “wrong” time.

5. True or false: The goal of treatment is to remove all anxiety so you never have
to feel it again.

6. Give two examples of exposures that could be helpful for someone who has a
fear of roller coasters. (Watch videos of roller coasters, watch other people
ride roller coasters, ride a small/large roller coaster)

7. True or false: Medicatio n is the only helpful treatment for anxiety disorders.

For the next three questions, I’ll give you choices, and you have to tell me which one is
the best option:

8. Here is a scenario: You wake up early and have anxiety about going to school.
What should you do?
A) Go back to bed. It’ll be easier tomorrow.
B) Get into an argument with Mom or Dad and hope they forget about taking
you to school.
C) Tell yourself that it may be hard to go, but you’re up for the challenge
and it will help your anxiety get better in the long run.

9. Which one of these is a goal of exposure therapy?

A) Totally freak you out and make you never want to come back to therapy.
B) Work as teammates with your therapist to help you boss back your
anxiety by slowly doing the things that make you nervous.
C) Take away all your anxiety so you never feel it again.
66 The Big Book of Exposures

10. Getting reassurance over and over again from friends, family, and your thera-
pist is:
A) A great solution to my problems
B) Something that sometimes feels good in the moment but doesn’t help my
anxiety in the long run
C) Something that we want to work to eliminate
D) Both B and C
 PART II

Getting Creative with Exposures for

Anxiety and Related Disorders
 CHAPTER 5

Specific Phobia

Part 1 provided an overview of exposure therapy as well as the general parameters for con-
ducting exposures with younger clients and adults. Now, in part 2, we will discuss the
various anxiety and related disorders for which exposure therapy is a large part of the treat-
ment. We have provided creative exposures for you to use with your clients in order for
them to be engaged, have fun (yes, it is possible), and target their core fears as best as pos-
sible. We begin with the specific phobias. In this chapter, we’ll cover the diagnostic criteria
as well as specific recommendations for you to keep in mind before diving into exposure.

WHAT ARE SPECIFIC PHOBIAS?

Approximately 16% of adults and adolescents have a lifetime history of specific phobia
(Kessler et al., 2012), making this the most common anxiety disorder. The DSM-5 (APA,
2013) criteria for specific phobia include the following:

A. The person has a marked, persistent, and excessive fear of a specific object or
situation.

B. Exposure to the feared object or situation almost always provokes an immedi-

ate anxiety response.

C. The feared object or situation is avoided or endured with intense distress.

D. The fear is out of proportion to the actual danger and the person’s social or
cultural context.

E. The fear is persistent (e.g., six months or more).

F. The fear or avoidance interferes significantly with the person’s functioning or

causes marked distress.

G. The symptoms cannot be better explained by another mental disorder.

In order to meet diagnostic criteria for a specific phobia, the fearful reaction that
clients experience when interacting with the feared situation must be intense or severe
and must occur nearly every time the individual encounters or even anticipates coming
into contact with the phobic situation.
70 The Big Book of Exposures

Types of Specific Phobias

While you can find exhaustive lists of specific phobias online (which many of you
have likely seen) that range from ablutophobia (fear of washing or bathing) to zelophobia
(fear of jealousy), in clinical practice, you’re likely to encounter a more limited number.
The specific phobias in the DSM-5 are divided into five main categories:

Natural Environment Type: This category includes a fear of heights, thunder and
lightning, and water.

Blood-Injection-Injury Type: This category includes fears of seeing blood, having

blood draws or injections, and visiting the dentist. This is the only category that
commonly includes fainting when presented with the feared situation.

Animal Type: This category includes fears of dogs, snakes, and insects.

Situational Type: This category includes fears of enclosed spaces or flying in

airplanes.

Other Types: This category includes fears that do not neatly fit into one of the
above-mentioned categories. Examples in this category can include fear of vomiting
or choking, among others.

Fear and Avoidance in Specific Phobia

Although people with specific phobias commonly describe their emotional reactions
as fear, in some cases, the emotion experienced is disgust (Davey, 1993). Clients with
phobias of some small animals (e.g., spiders) often describe the feared animal as disgust-
ing rather than scary (de Jong, Andrea, & Muris, 1997). Similarly, clients with blood-
injection-injury phobias may be particularly likely to describe their emotional reaction as
disgust rather than fear (Sawchuk, Lohr, Tolin, Lee, & Kleinknecht, 2000). Disgust,
thought to represent an evolutionary defense against contagion and disease (Rozin &
Fallon, 1987), may be characterized by parasympathetic, rather than sympathetic,
nervous system activation (Levenson, 1992). Some studies reported that clients high in
disgust sensitivity, a trait-like predisposition to experiencing disgust, demonstrated less of
an improvement in spider phobia symptoms following exposure therapy than did those
low in disgust sensitivity (Merckelbach, de Jong, Arntz, & Schouten, 1993). Disgust
during exposure usually does decrease over time; however, disgust reactions may decrease
more slowly than do fear reactions (McKay, 2006; Olatunji, Smits, Connolly, Willems, &
Lohr, 2007; Smits, Telch, & Randall, 2002), possibly indicating the need for more repeti-
tion of exposures (Vansteenwegen et al., 2007).
Specific phobias are usually characterized by a maladaptive pattern of avoidant
behavior. For example, individuals with fears of storms might avoid going outside when
the weather is bad. Those with blood-injection-injury fears might avoid having blood
draws, injections, or trips to the doctor. Individuals with animal phobias might avoid
Specific Phobia 71

going anywhere near the feared animal, which could include avoiding everyday activities
like going for a walk, for fear of seeing someone else walking a dog. Those with flying
phobias might avoid air travel altogether or might fly only with excessive use of alcohol
or benzodiazepines (safety behaviors).

Important Considerations in the Treatment of

Specific Phobia
There is some conceptual overlap between specific phobia and other anxiety-related
disorders. For example, a client with a specific phobia and one with agoraphobia might
both be afraid of enclosed spaces or crowds. However, in the case of agoraphobia, it’s
important to note that the core fear is of panic-like or other embarrassing symptoms (e.g.,
throwing up, having diarrhea), rather than the situation itself. That is, an individual with
agoraphobia is afraid not so much of an airplane crash (which might be the case in a
specific phobia of flying), but rather of the possibility that he or she will have panic symp-
toms on an airplane and won’t be able to escape the situation or get help. It’s also noted
that individuals with OCD might be afraid of blood; however, for those clients the core
fear is usually that they will become contaminated, rather than fearing (or being dis-
gusted by) the sight of blood (as would be the case in specific phobia).

BEHAVIORAL TREATMENT FOR

SPECIFIC PHOBIA
In the remainder of this chapter, we provide creative exposure ideas for the phobias you
are most likely to encounter in your practice. However, it is our hope that once you are
familiar with how to design and implement exposures, you will be able to successfully
treat clients with any phobia who may walk through your door. We have chosen to list
the exposure ideas from what many clients consider easiest to what many consider most
challenging. However, it is important to note that every hierarchy you create with your
client should be individualized. Some items that we list as a lower-level exposure may be
at the top of your client’s hierarchy of fears. Take the time to sit down with your client
and rate these items from 0 to 100 (and generate your own ideas!).
For each type of phobia, we provide both “in-office” and “out-of-office” exposures.
Note that all “out-of-office” exposures can be done with you and your client first, or you
can assign any of the exposures for therapy homework.

Natural Environment Phobias

This category includes a fear of weather events such as storms. Often it will be
helpful to use imaginal exposure or virtual reality equipment to target many of these
specific phobias—for example, to have a client experience a tornado—as they can be
challenging to recreate in an office setting.
72 The Big Book of Exposures

Exposures for Fear of Storms

In-Office Exposures: STORMS

• Listen to audio clips of thunderstorms or tornados on your phone or computer.

Search online for “loud thunder clip” or “tornado sounds.” You can have your client
sit at your desk and type this into a search engine, or you can do it yourself with the
client sitting next to you. You may want to begin with the volume low and then slowly
increase it to make the exposure more challenging. You may find that one small
piece of the clip is highly anxiety provoking, so you can keep playing that segment
again and again for the client. Refrain from talking too much during the exposure
as you do not want it to become a distraction for the client.

• Watch video clips of storms (e.g., hurricane, thunderstorm, blizzard, tornado)

or earthquakes on your computer. Do an online search of “big storms” or “deadly
storms.” You can also consider having your client watch storm scenes from movies
such as Twister or The Perfect Storm. Consider variables such as the volume on the
video clips by starting it low and increasing it with future exposures. When this no
longer is challenging, encourage your client to imagine being in the middle of the
storm.

• Write an imaginal exposure script of being in a feared storm. Encourage the

client to write a present-tense story about being in a terrible storm. Be specific! You
can use the sample imaginal exposure script at the end of this chapter for
inspiration.

• Read online news stories of powerful storms. Have the client search for and
read scary stories about storms. Alternatively, you can read stories about deadly
storms aloud to your client while he closes his eyes and pictures the story in his mind.
It may be more challenging to have the client read the story aloud to you, so keep
this in mind while creating the hierarchy.

• Simulate thunder noises by drumming on a piece of sheet metal. Once the client
is comfortable with this, you can make these sounds outside of the window while he
sits in the office alone, to be more realistic. You can also pair this with other expo-
sures, such as when the client is reading his imaginal exposure script.

• Use virtual reality (VR) equipment. Some VR packages offer a “storm” package
that can be used to help the client feel more immersed in the situation. Have the
client wear the headset and/or headphones. If it is too challenging to wear both
together, have the client do one at a time before combining them for the full storm
experience.
Specific Phobia 73

Out-of-Office Exposures: STORMS

• Watch the weather channel. If the client has been avoiding watching the news or
weather for fear of thinking about or learning about upcoming storms, then it will
be important to include exposures that allow the client to face this fear. Ask your
client to keep the weather channel on while at home and also to watch episodes of
shows that depict dangerous, and even deadly, storms.

• Visit a science museum. Sometimes science museums will have weather exhibits or
simulators that replicate the experience of being in a storm, such as stepping inside
of a wind machine, or hearing what it sounds like to be near a tornado or other kind
of storm. Conduct an online search to see what exhibits may be present in your local
museums.

• Sit outside during a storm. Encourage the client to sit on the porch or deck of his
home when there is a storm (of course, if it is not hazardous to do so).

Safety Behaviors to Eliminate: STORMS

Watch for signs of avoidance, such as your client going into the basement at any sign of
a storm. Work with your client to eliminate this behavior, unless it is clearly necessary.

Watch also for excessive checking behavior, such as excessively checking the weather
online to ensure that there are no storms coming. If these behaviors serve to lower the
client’s anxiety by reassuring him that no storm is coming, encourage the client to stop
checking the weather. We are aware that earlier, we talked about watching the weather
as an exposure. While it might seem like we’re contradicting ourselves when we talk
about eliminating this behavior, the distinction comes from what the client is currently
doing. If the client is compulsively checking the weather as a means of reassuring himself,
encourage the cessation of that behavior. Conversely, if the client is avoiding looking at
the weather, encourage approach. The bottom line is that we want to reverse the client’s
current pattern of maladaptive behavior.
74 The Big Book of Exposures

Blood-Injection-Injury Phobias
Clients with blood-injection-injury (BII) phobias may fear going to the dentist or
doctor, having injections, or having blood draws (or watching these happen to someone
else). Some clients with BII phobias exhibit a vasovagal response, in which they faint or
feel faint during or after exposure to the feared stimulus. In such cases, it’s important to
include an intervention to prevent fainting during exposure therapy. Applied tension
(Kozak & Montgomery, 1981) is one such intervention. This method instructs clients to
tense or “pump” their torso and thigh muscles repeatedly, which helps prevent pooling of
the blood and increases blood flow to the brain. In BII phobia with vasovagal response,
exposure with applied tension yields significantly better results than does exposure alone
(Öst, Fellenius, & Sterner, 1991).
If your client is prone to fainting, be sure that you are conducting exposures in a
manner and location that will not harm the client if he falls. Clients can engage in expo-
sure exercises while sitting or reclining in a comfortable chair with arms, which not only
improves blood flow to the brain, but also protects them from fall injuries. In case of
actual fainting, the World Health Organization (2010) recommends having the client sit
or lie in a reclined position, loosening any restrictive clothing, monitoring blood pressure
if possible, giving the client something to drink, and offering reassurance. Recovery from
fainting is usually rapid. An important psychological component of the intervention, in
our opinion, is to “de-catastrophize” fainting so that the client does not view it as a
failure experience or as the end of the world.
Specific Phobia 75

Exposures for Fear of Blood, Injections, and Surgery

In-Office Exposures: BLOOD, INJECTIONS, SURGERY

• Look at online pictures of needles, blood, or people receiving injections. You

can start with having your client view cartoon pictures and increase to more intense
pictures once the client has a sense of mastery over the easier ones. Have your client
describe what he sees in the picture so that you can make sure the client is not
engaging in subtle avoidance behaviors. For example, if the client is looking at a
picture of a person receiving a blood draw, you can ask him to describe how the
person looks (e.g., scared, relaxed), how big the needle is, if any blood is shown and
how deep the color of the blood is, how the nurse looks taking the blood, and so on.

• Use an alcohol swab. Rub the client’s arm with rubbing alcohol to simulate pre-
injection procedures.

• Use a tourniquet. Tie a tourniquet around the client’s arm to simulate pre-blood-
draw procedures.

• Look at and hold a syringe. Keep the cap of a syringe on at first, then remove the
cap, and then have the client practice removing the cap. Get comfortable playing
with syringes!

• Hold a syringe to the client’s arm. With the client’s permission, place a syringe on
his arm. This can first be done with the cap on, and then later you can do this expo-
sure with the cap off of the syringe.

• Use a blunt needle. You can order blunt needles online and practice pressing them
to the client’s skin, as was done with the syringe example above.

• Use imaginal exposure to feared consequences. Work with your client to create
an imaginal exposure script of fainting (or whatever the target feared outcome is)
after getting an injection or a blood draw. Reference the sample imaginal exposure
script at the end of the chapter.

• Look at pictures of injections. Conduct an online search with your client, which will
provide you with a great range of pictures, from cartoons to photographs, ranging
in degree of “bloodiness.” Ask your client to rank these according to fear level.
Keep a folder on your computer, or bookmark pages or pictures online, of those that
were particularly challenging for your client so you can easily access them again for
future exposures.

• Watch instructional videos. Conduct an online search with your client. Search
terms such as “how to give an injection” or “how to draw blood” yield lots of clips.
Sit with your client and watch these clips repeatedly. If the video is long, you can ask
the client which part creates the most anxiety and then watch that portion of the clip
76 The Big Book of Exposures

repeatedly. You can also ask your client to describe exactly what is going on in the
clip to make sure he is not engaging in cognitive avoidance by thinking about some-
thing else in order to feel less anxious.

• Watch videos of blood draws. Search online for “blood draw” or “venipuncture.”
Watch these videos with your client.

• Watch videos of surgeries. Search online for “thoracic surgery videos” or “plastic
surgery videos.” Have the client scan the video options and begin watching ones
that are lower on the hierarchy and then move up to more challenging ones once the
first ones are no longer anxiety producing. You can adjust the volume and the video
screen size on your computer to titrate the dose of exposure—perhaps, for example,
starting with a very small and quiet viewing, then gradually increasing the size and
volume.

• Watch scary movie scenes. The movie Saw II, for example, has a clip with a person
who jumps into a “needle pit.” The movie The Shining has a scene in which blood
comes gushing out of an elevator. The movie Carrie has a scene in which the title
character gets covered with a bucket of blood. The movie Reservoir Dogs has mul-
tiple scenes of an injured character covered with blood. You and your client can find
these movie clips online.

• Test blood sugar. You or your client can purchase an inexpensive kit at a drugstore
or online to test his blood sugar by pricking his finger. You can later pair this expo-
sure with the imaginal exposure script that the client created or with watching feared
online clips of blood or injections.
Specific Phobia 77

Out-of-Office Exposures: BLOOD, INJECTIONS, SURGERY

• Sit for a blood draw without getting one done. Have the client visit a phleboto-
mist or clinical laboratory (better yet, go with the client) and sit in the chair as if he
were going to get an injection. Call ahead to the site and see if they will allow this.

• Watch an injection. If you, or the client’s friend or family member, have an injection
or a blood draw scheduled, encourage the client to come and watch.

• Watch others donate blood. Find out where the local blood drive is and then have
the client visit the site (better yet, accompany the client to this) without any pressure
to donate.

• Go for acupuncture. Schedule an appointment for acupuncture. During an acu-

puncture appointment, thin needles are placed into specific places on the body.

• Get an injection. Encourage the client to schedule a flu shot, blood draw, or other
medically indicated injection. Accompany him if you can.

• Donate blood. Encourage the client to donate at a local blood drive.

78 The Big Book of Exposures

Exposures for Fear of the Dentist

In-Office Exposures: FEAR OF THE DENTIST

• View pictures of dental visits. You can start by having your client look at cartoons
of experiences at the dentist and increase this to more intense pictures once the
client has a sense of mastery over the easier ones.

• Listen to the sound of a dentist’s drill. Start by having your client listen to sounds
of the drill alone and then add audio clips of a dentist drilling while someone is in
pain or crying (search online for “dentist drill sounds”). Start with the volume low and
steadily increase it to make the exposure more challenging. As the exposure
becomes easier, encourage the client to imagine himself in the dentist’s chair. Have
your client repeatedly state, “This could be me.”

• Watch videos or clips online. Search for “videos of dentist drilling cavity.” Sit with
your client while watching these.

• Watch videos of having teeth pulled. Search for “tooth extraction,” and then later
move to more challenging exposures such as “painful tooth extraction” or “tooth
extraction gone wrong” and watch these together.

• Use imaginal exposure to feared consequences. Work with your client to create
an imaginal exposure script of going to the dentist (or something bad occurring at
the dentist). Once the client exhibits some degree of mastery over that task, have
him read the script while an audio clip of drilling is playing in the background. There
is an example imaginal exposure script provided at the end of the chapter.
Specific Phobia 79

Out-of-Office Exposures: FEAR OF THE DENTIST

• Drive to the dentist’s office. Drive with your client or ask him to go alone and sit in
the parking lot without going into the office. Bring along the client’s imaginal expo-
sure script and ask him to read it while sitting in the parking lot of the dentist’s office.

• Sit in a dentist’s waiting area. With the dentist’s permission, ask your client to sit
in the dentist’s waiting room without an appointment and observe what is occurring.
He can also silently read the exposure script in the waiting room for a more chal-
lenging exposure.

• Take a tour. Have your client call ahead and ask to take a tour of the dentist’s
office.

• Attend someone else’s dental appointment. Have your client go to a dental

appointment with a friend or family member to watch what he has done (bonus
points for viewing a cavity filling!).

• Sit in a dentist’s chair. Have your client call ahead to the dentist’s office and ask
to sit in the chair and have the instruments (e.g., mirror) in his mouth.

• Get a dental cleaning. Ask your patient to have a dental cleaning with no cavities
being worked on.

• Complete dental work that has been delayed. Have the client get a cavity filled
or any other procedures done.

Safety Behaviors to Eliminate: BLOOD, INJECTIONS, SURGERY;

FEAR OF THE DENTIST

Many fearful clients take anxiolytic medications, such as benzodiazepines, before

medical and dental procedures. Encourage the client to try these exposures without such
medications, choosing instead to feel the fear and tolerate distress.

Watch for excessive reassurance-seeking. Asking once whether a procedure is likely to

hurt is probably fairly normal. However, asking again and again for the purpose of
feeling better is likely a safety behavior. Encourage the client to limit reassurance-
seeking questions.
80 The Big Book of Exposures

Animal Phobias
Commonly seen fears within this category are of snakes, dogs, and bugs.

Exposures for Fear of Snakes

In-Office Exposures: SNAKES

• Look at online pictures of snakes. Start with having your client view cartoons and
increase this to viewing more intense pictures (e.g., snakes shedding skin, snakes with
large fangs, deadly snakes) once the client has a sense of mastery over the easier
ones. Talk about what the client sees in each of these pictures.

• Change the background/screensaver of a phone or computer. Have the client

put a picture of a snake as the background picture on his phone or on the desktop
of his computer.

• Talk about snakes. Go back and forth with your client, coming up with words to
describe snakes or their behavior (e.g., slithering, hissing, menacing, shedding skin).

• Watch video clips of snakes. Do an online search with your client for “videos of
nice snakes” and then “videos of dangerous snakes” or “videos of snake biting
someone.” As is the case for other visually mediated phobias, you can change the
dose of exposure by adjusting the size and volume of the video.

• Create an imaginal exposure script. Have your client include details in the story
of coming into contact with a snake. Add what it feels like on the skin to hold the
snake or to have it around one’s neck. Reference the sample imaginal exposure
script at the end of the chapter.

• Wallpaper the home. Print out pictures of various types of snakes, and give them to
the client to hang up on the walls of his home to constantly be in contact with the
feared stimulus.

• Play with rubber snakes. Order rubber snakes and put them on the office floor.
You can also ask the client to hold the rubber snakes while going through other
exposures, such as reading his imaginal exposure script aloud or watching videos of
snakes.
Specific Phobia 81

Out-of-Office Exposures: SNAKES

• Get a new wallpaper for the phone or computer. Have the client put a picture of
a snake on the phone or computer lock screen or wallpaper.

• Watch an entire movie about snakes. For a homework assignment, have the client
watch a documentary about snakes or a thriller movie such as Snakes on a Plane.

• Visit a pet store. Go with the client to the pet store if you can. Have the client take
pictures of the snakes. The client can ask an employee to see the snake out of the
cage (without holding it). Later on, ask the client to touch the snake or hold it. This
may unfold over the course of several sessions.

• Go on a snake hunt. Go into the woods with your client on a “hunt” for snakes.
Depending on where you go into the woods, it is fairly unlikely that you will come
into contact with a snake, but the goal of the exposure is to have the client be willing
to come into contact with one.

• Have rubber snakes placed randomly throughout the home. You can encourage
your client to place rubber snakes randomly in his home to target the fear of being
startled by these creepy crawly creatures. You can even ask the client’s family
members to be the ones in charge of placing these rubber snakes, with the client’s
permission. To make it more challenging, you can ask family members to randomly
move them around the house throughout the week.

• Visit a reptile house. You can conduct an online search to find a nearby reptile
house and go for a visit. You may be able to call ahead to ask if you can have a
private showing of a snake and/or the opportunity to hold one.
82 The Big Book of Exposures

Exposures for Fear of Dogs

In-Office Exposures: DOGS

• Look at pictures of dogs. Begin by having your client view pictures of cute puppies
and work up to looking at pictures of bigger dogs, drooling dogs, or menacing-
looking dogs. Have your client describe the details in the pictures.

• Read scary stories about dogs. Search online with your client for stories of dogs
biting or attacking someone. Either read the stories aloud to your client or have your
client read them aloud in the session.

• Watch video clips of dogs. Search online with your client for video clips of dogs
doing cute things, and then work up to watching videos of barking dogs, dogs who
jump, and a dog biting someone.

• Create an imaginal exposure script. Collaboratively create a story with your

client of dogs attacking/biting/jumping around. Include details about how the dog
smells, how it feels, what the barks sound like, and so on. Reference the sample
imaginal exposure script at the end of this chapter.

• Pet a dog. If you have (or have access to) a dog, you can have the client touch the
dog’s face or mouth in session. Start with smaller dogs and work up to having the
client be around larger dogs or jumpier dogs. You can begin with the dog on the
leash and then consider having the dog off the leash when the client is more
comfortable.
Specific Phobia 83

Out-of-Office Exposures: DOGS

• Visit a pet store. Have your client go to a local pet store, where dogs are likely to
be with some of the customers, either walking around the store or getting groomed.
Once this becomes easier, the client can ask to hold or pet a dog in the pet store.

• Go to a friend’s or family member’s home. Ask your client to visit a friend or

family member who has a dog and spend some time in the house without having the
dog be put outside or in another room.

• Give treats. Have the client give a dog a treat from his hand.

• Get licked by a dog. Let the dog lick peanut butter off the client’s hand.

• Visit an animal shelter. Have the client visit an animal shelter or volunteer at one.

• Become a pet sitter. Encourage the client to ask to pet sit a friend’s or family mem-
ber’s dog for one night.

• Visit a dog park. Have your client stand outside the gate of a dog park and watch
the dogs play. Accompany your client to the dog park, if possible. Once this becomes
easier, have the client stand inside the gate of the dog park and watch the dogs
play, or even throw balls for the dogs. Have the client move increasingly toward the
center of the park and refrain from standing only in a spot where no dogs are
playing or running around.
84 The Big Book of Exposures

Exposures for Fear of Bugs

In-Office Exposures: BUGS

• Look at pictures of bugs. Start by looking at cartoon pictures of all different kinds
of bugs (e.g., bees, cockroaches, flies, palmetto bugs), and then look at real pictures
of these bugs online.

• Watch video clips of bugs. You can search online for insect videos, perhaps pro-
gressing to searches such as “people eating bugs” or “bug infestation.”

• Eat fake bugs. Have the client eat chocolate or gummy candy in the shape of an
insect (without actually eating an insect…that can come later!).

• Make a bug purchase. Have the client search online for, and then make an online
purchase of, dehydrated bugs or tarantulas. Ask the client to bring them into session
so that you can use them together for exposures.

• Create a drawing. Have the client draw a bug that is most terrifying to him. Ask the
client to hang the picture up in a visible area of his home.

• Create an imaginal exposure script of bugs. Work with your client to create a
detailed story of coming into contact with a bug. Make sure to add details to the
story, such as how the bug feels crawling on the client and what noises (if any) the
bug may make. Reference the sample imaginal exposure script at the end of the
chapter.

• Search for bugs. Go on a “bug hunt” with your client and see who can spot the most
bugs (and keep track!). Use the tracking sheet provided at the end of the chapter to
play the bug game!

• Look through a bug bag. Have a bug bag on hand of dead bugs you’ve found.
Have the client look at items in the bug bag without touching them.

• Touch a bug. Have the client reach into the bug bag and pull one out without
looking at it.

• Have a bug on the body. Have the client put a dead bug on his lap. Work up to
making the exposure more challenging by placing the bug on his bare skin.

• Play a game of “catch” with a toy bug/spider or a real (dead) one. Throw the
bug back and forth with your client while saying words to describe the bug, such as
“slimy” or “gross.”

• Catch a live bug. Have your client catch a live bug and try to hold it or place it on
his skin.

• Eat real bugs. Have the client eat a chocolate covered ant, grasshopper, cricket, or
other insect that you can order online. Search online for “buy edible bugs.”
Specific Phobia 85

Out-of-Office Exposures: BUGS

• Change the wallpaper on an electronic device. Ask your client to put pictures of
creepy, crawly bugs on either the lock screen of his phone or on the wallpaper of
either his phone or computer. You can review this weekly in session and change it to
more challenging photos each week.

• Visit a science museum, “insect zoo,” or museum of natural history. Some

museums will have exhibits on bugs, 3D movies about bugs, and sometimes an
opportunity to touch bugs. There are several “insect zoos” and butterfly pavilions
around the country as well, including at the Smithsonian. Check your local museums
for more ideas to be used for exposure.

• Visit a pet store. Encourage your client to go to a pet store (with you, if possible)
and look at all of the creepy crawly insects. Often, pet stores will sell crickets or
roaches. The client can also purchase one to bring home to use for future
exposures.

• Create a client bug bag. For homework, have the client go out and create his own
bag of dead bugs and bring it to the next session.

• Bring a bug home. Allow the client to bring home one of the bugs that you both
collected (or from your bug bag) and put it on the bedside table.

Safety Behaviors to Eliminate: SNAKES; DOGS; BUGS

Many clients who engage in animal exposures tense their bodies, as if preparing to jump
away from or otherwise avoid contact with the animal. Encourage a relaxed posture. It
is also common for clients to hold their arms straight out when touching the feared
animal, in order to keep the animal at arm’s length from the body. Encourage closer
contact.

Touching exposures often begin with just a fingertip. While this is acceptable as a first
step, it can be a way for the client to minimize the exposure and feel safer. Encourage
the client to use the whole hand (including the palm).

Discourage excessive reassurance-seeking. Asking once whether a snake, dog, or bug is

likely to bite is a reasonable question, but it becomes a safety behavior when asked
repeatedly. Encourage the client to limit reassurance-seeking questions.
86 The Big Book of Exposures

Situational Phobias
Situational phobias include excessive fears of specific situations such as heights,
flying, and being in tight spaces.

Exposures for Fear of Heights

In-Office Exposures: HEIGHTS

• Watch video clips. Watch clips of people falling from high places. Conduct an
online search for the movie The Walk to see a man tightrope across two high
buildings.

• Read stories. Read stories of people who have been trapped high up on roller
coasters or other structures. You can conduct an online search for “people who were
stuck on roller coasters.”

• Use virtual reality equipment. Use VR equipment to help the client feel as if he is
high off the ground.

• Create an imaginal exposure script. With your client, create a detailed script of
being high off the ground and include details of the client’s feared outcome (e.g.,
falling, death).

• Go up to the top of a building. Take your client to a higher floor of the office build-
ing or parking garage, if possible. Have the client look down and repeatedly state,
“I’m going to fall.”
Specific Phobia 87

Out-of-Office Exposures: HEIGHTS

• Go to the top of a parking garage. Ask your client to either walk or drive up to the
top of a parking garage and stand close to the edge while looking down.

• Climb a ladder. Ask your client to practice going higher and higher up a ladder.
You can even start out with a small step stool.

• Visit an amusement park. Have your client go to an amusement park and look up
at the rides without any pressure to ride them.

• Get in line. Have your client get in line to go on a high waterslide or tall ride without
following through and getting on the ride.

• Ride the escalator. Ask your client to ride an escalator in a shopping plaza while
looking over the side. Ask your client to repeatedly think, I could fall over the edge.

• Take an elevator. Ask your client to ride in elevators in tall office buildings (this is
often easier in a big city or in a hospital or business building). Glass elevators are
also great options. Have the client start by just going up one floor and then work up
to taking the elevator to the top floor. Standing with his forehead against the glass
and looking down can intensify the sensation.

• Cross a bridge. Look up some nature walks or other places nearby where a client
can visit a bridge to cross. Adjust the level of difficulty by changing up variables
such as how old the bridge is, how high it is, and whether the client walks or drives
on it.

• Go on a ledge walk. Depending on where you are located, there may be oppor-
tunities for your client to not only go to an elevated location but to also see directly
beneath him due to a glass floor. Examples of such places in the United States
include the Sears Tower and the Grand Canyon.

• Go on a Ferris wheel or roller coaster. Start by having your client ride smaller
rides at the amusement park until he works up to riding on larger ones or ones that
go higher and higher.
88 The Big Book of Exposures

Safety Behaviors to Eliminate: HEIGHTS

When the client is visiting a high place, he may keep far away from the edge as a safety
behavior. Encourage the client to go as close to the edge as is safe. Also, when handrails
are available in a high spot, some clients will grip them tightly, reducing their fear of
falling. Encourage the client to let go of the handrail if it is safe to do so.

Some clients, in a high place, will avoid looking down. Sometimes this is because the
client is trying to “forget” the height; in other cases, the client fears that looking down
will cause vertigo, which then increases falling risk. Of course, true vertigo or other physi-
cal balance problems need to be considered carefully. However, in most cases, it is safe
for the client to look down, and we recommend that he do so.
Specific Phobia 89

Exposures for Fear of Flying

In-Office Exposures: FLYING

• Listen to sounds of a plane. Do an online search with your client for airplane
sounds. Allow this noise to play in the background while the client reads his imaginal
exposure script.

• Read stories. Read stories with your client about scary or turbulent flights that
ended well. Later the client can read stories about plane crashes. You can search
online for “turbulent flights” or “scariest flight stories.” He can read these stories
aloud or you can read the stories to the client depending on how it is rated on the
hierarchy.

• Create an imaginal exposure script. Work with your client to have him create a
detailed script of a plane crashing or some other feared outcome (e.g., turbulence).
Reference the imaginal exposure script at the end of the chapter.

• Watch videos of flying. There are many videos of flying available online that
include take-off, landing, and what happens in flight. Some videos include smooth
flights, while others have turbulence. Change these variables depending on the level
of the client’s anxiety and fear. After the client feels more comfortable with videos
of turbulence, you can have him pair the videos with interoceptive exposures such as
shaking or being jostled in a chair to simulate motion.

• Use virtual reality equipment. Have your client simulate the experience of being
on a plane by using VR equipment.

• Watch videos of plane crashes. Several movies, including Cast Away, The Grey,
and Final Destination, have clips of airplane crashes, from the passengers’ point of
view. You can find these clips online.
90 The Big Book of Exposures

Out-of-Office Exposures: FLYING

• Drive to an airport. Encourage you client to drive to the airport and sit in the
parking lot without planning to take a flight.

• Sit in the waiting area. Have your client enter the airport, walk around, and sit in
the ticketing area.

• Take a ride. Ask your client to schedule and attend a helicopter tour of a city.

• Take a short flight. Encourage your client to schedule a short flight. Often there are
deals for flights that are less than $100.

• Take a cross-country flight. Have your client schedule a trip to a destination that
he has previously avoided due to fear of flying.

• Take an international flight. Have your client take an international flight to an

exciting destination.

• Take a flying lesson. Ask your client if he would be willing to sign up for a flying
lesson.

Safety Behaviors to Eliminate: FLYING

Alcohol and benzodiazepines are among the most commonly used safety behaviors
when flying. Encourage the client to refrain from the use of sedating substances and to
practice distress tolerance instead.

Some clients will “white-knuckle” the armrest on a plane, as if to keep the plane from
crashing (we’ve even observed this phenomenon during VR exposure). Recommend a
more relaxed grip.

A fearful flyer will often avoid looking out the window or looking around the plane
(sometimes by keeping his face buried in a book or his eyes closed while listening to
headphones). Encourage the client to look around and engage fully with the situation.
Specific Phobia 91

Exposures for Fear of Tight Spaces

In-Office Exposures: TIGHT SPACES

• Look at pictures of enclosed spaces. Search online with your client for “claustro-
phobia pictures” and look through the items together.

• Watch videos. Conduct an online video search of people who have been trapped
in caves or other small spaces and watch those together.

• Say scary phrases. Have your client close his eyes, picture a small space, and
repeatedly say, “I’m trapped and can’t get out.”

• Create a detailed imaginal exposure script. Work with your client to create a
detailed story about being trapped in a small space. Encourage your client to
include lots of details in the story, such as the room or area feeling hot, becoming
sweaty, and being unable to move around easily.

• Have the client cover part of the face. Have client wear a doctor’s mask that
covers the mouth and nose.

• Place the client in a small area. Ask the client to step into a small closet or small
room. He can first do this alone and can then have others join him in a small room or
closet to make it feel increasingly claustrophobic.

• Say the worst fear aloud while in a small space. Have the client go in a locked
closet or room and repeatedly say, “I’m in a small space and can’t get out.”

• Go into an elevator. Step into an elevator with your client and stand inside it with the
doors shut. Do not press a button to go to the next floor, so the elevator doesn’t move
and mimics the feeling of being stuck or trapped. This can be paired with the above
exposure in which the client repeatedly states, “I’m in a small space and can’t get out.”

• Wear a mask. Have the client wear a Halloween-type mask that covers most of the
face.

• Be a burrito. Ask the client to roll himself up into a rug, long blanket, or sheet until
he is unable to move easily.

• Get into a sleeping bag. Get a sleeping bag or have the client bring one from
home. Ask him to get into the sleeping bag head first.

• Lock the client in a small closet, car trunk, or small room. Yes, we know it’s weird,
and this is likely a high-level exposure that needs to be discussed and negotiated
carefully within the context of a trusting therapeutic relationship. But for clients who
are fearful of being trapped, it can be a useful experience. We recommend that at
least at first, you remain right outside the door and talk the client through the
exposure.
92 The Big Book of Exposures

Out-of-Office Exposures: TIGHT SPACES

• Be in a small closet. Have your client go into a small space or closet in his home in
order to come in contact with that feared sensation of being closed in. To make it
more challenging, the client can get into a sleeping bag in the closet or have a
friend or family member wrap him up tightly in a blanket in the closet, and then shut
the door.

• Go into a mock MRI. Have your client practice going into a mock MRI (some hospi-
tals have these so that clients can acclimate to the scanner before having a real
scan).

• Ride a crowded subway. Have your client ride on a crowded subway or bus at rush
hour.

• Go to a movie theater, concert, crowded church, or sporting event. Have your

client go to a movie theater or other seated area, and encourage him to sit in the
middle of the aisle so that he is unable to get out easily.

• Do an “escape room.” Escape rooms are adventure games in which players need
to find clues and solve puzzles in order to escape a room before the clock runs out,
which is usually an hour in length. Some of the rooms have locked doors, which will
mimic the feeling of being in a small space and being unable to get out easily. In
addition, in some of the more advanced rooms, players are handcuffed for a short
period of time and need to find the key to “escape.” These rooms often come with
warnings that someone who is claustrophobic may not like the atmosphere and
notify patrons in the beginning that they may leave the room at any time. Therefore,
you and your client should explore these factors first before deciding which escape
room to do.

Safety Behaviors to Eliminate: TIGHT SPACES

Many clients with a fear of tight spaces will use deep breathing strategies to try to relax.
This is not only a counterproductive safety behavior, but it also contributes to hyperven-
tilation (which can be an exposure in its own right, if one is treating panic disorder). In
most cases, we discourage the use of deep breathing as a coping strategy.

Some clients, when in a tight space, will avoid looking around or will even close their
eyes, trying to trick their brain into forgetting where they are. Encourage the client to
look around, recognize where he is, and tolerate the resulting distress.
Specific Phobia 93

Other Types of Phobias

The “Other” category of phobias includes fears that do not neatly fit into one of the
above-mentioned categories. Examples in this category can include fear of coming into
contact with vomit (or vomiting) and fear of choking.

Exposures for Fear of Vomit/Vomiting

In-Office Exposures: VOMIT/VOMITING

• Play a vomit word game. Play a game where you and your client, and anyone else
who is with you during the exposure (e.g., confederate, client’s parent), has to alter-
nate saying words that either describe vomit or are synonyms for the word vomit.
Here are a few suggestions: chunky, beefy, bile, oozing, wet, barf, blow chunks,
puke, projectile vomit, splattering, thick, juicy, heave, hurl, regurgitate, spew.

• Listen to sounds of vomiting. Search online for audio files of “vomit sounds.” You
can start the volume low and slowly increase it to make the exposure more challeng-
ing. You can later ask your client to try to mimic the sounds that he hears in the
videos.

• Look at pictures of people vomiting. You can start with having the client look at
cartoon characters vomiting and then advance to real people getting sick. The
website http://www.ratemyvomit.com has literally thousands of photographs of
people throwing up.

• Play the jelly bean game with your client (see additional page for directions).
Have your client eat gross-flavored jelly beans (such as vomit, skunk, or spoiled milk)
to target feeling sick or as if he could vomit. You can play this game as a way to
make the exposure more fun—younger clients especially love it. You will need to
purchase BeanBoozled Jelly Beans, which are made by Jelly Belly. There are some
packs of jelly beans you can purchase that come with a spinner. For these, the client
will have to eat the jelly bean the spinner lands on. There are other jelly beans that
come in a canister that pushes one jelly bean to the top, so you never know which
one will be the one you get.

• Eat vomit-flavored jelly beans. Have your client eat vomit-flavored jelly beans
while watching video clips of people vomiting. You can also search for “BeanBoozled
challenge” to view clips of people gagging or even vomiting while eating the jelly
beans.
94 The Big Book of Exposures

• Make fake vomit. Make a concoction with your client that looks like vomit.
Here’s a recipe for fake vomit:*
2 cups cottage cheese
¼ cup sour cream
1 package onion soup mix
1 small carrot (diced)
4 drops or more of yellow food coloring
Here’s another fake vomit recipe:
1 can beef and barley soup
1 can cream of mushroom soup
½ cup sweet relish
½ cup vinegar

• Fake vomit into toilet. Take the created vomit concoction and have the client stand
over the toilet and mimic sounds of heaving while plopping some of the mixture into
the toilet. Be sure to encourage your client during this time by saying things like
“Whoa, you got a lot up that time!”

• Use a tongue depressor. Ask your client to put a straw or tongue depressor in his
mouth to get the gag reflex going. The point of this exercise is not to induce vomit-
ing, but rather to feel the sensations of gagging.

• Watch a video clip of someone vomiting. Watch online videos together of people
vomiting. You can begin with cartoon characters vomiting and then advance to real
people vomiting. You can find seemingly endless examples online. Ideas from car-
toons include a Family Guy episode where there is an ipecac drinking contest (Season
4, episode 8). Ideas from popular movies include Pitch Perfect, in which a character
vomits on stage while performing, Monty Python’s The Meaning of Life, which has a
cartoonish scene of repeated vomiting, and Stand By Me, which contains a rather
preposterous scene of an entire crowd of people vomiting.

• Consume food or drink that was previously avoided due to fear. Rank order a
list of foods that your client avoids due to fear of vomiting, and systematically work
up the hierarchy, allowing him to try each item repeatedly until the anxiety comes
down. Many times, clients are wary of dairy items or raw items such as sushi. You
can ask your client to bring in a feared item (e.g., yogurt), and then after the expo-
sure, tell him you will keep it in your refrigerator until the next session for him to taste
(we wouldn’t do this with sushi, though). This is particularly effective since the client
can’t check it, and the item will already have been opened and “exposed” to other
things in the refrigerator that the client may fear could make him sick.

* We’d like to thank our colleague Mary Alvord for passing these recipes along.
Specific Phobia 95

Out-of-Office Exposures: VOMIT/VOMITING

• Wallpaper the home with pictures of vomit. Print out cartoons of vomit or charac-
ters vomiting and have your client “wallpaper” his house (or bedroom) with the
pictures to constantly be exposed to the feared stimulus. Once this becomes easier,
you can have the client hang more graphic pictures of vomiting around the house or
a room in the house.

• Get a new wallpaper for the phone or computer. Have the client put a picture of
a cartoon or real person vomiting on the phone or computer lock screen or
wallpaper.

• Go to a party. Ask your college-aged students to attend college parties as there

may be others there who are intoxicated and throwing up.

• Go to a restaurant. Ask your client to go to a restaurant and eat previously avoided

food, such as sushi or a hamburger/steak that is cooked at a medium or a medium-
rare temperature.

• Visit a hospital. Have your client walk around a hospital, where he could come into
contact with a person who is sick who poses a risk of contamination and subsequent
vomiting.

• Visit a theme park. Encourage your client to ride on a roller coaster or other ride
that could lead to motion sickness (and therefore a risk of vomiting).

Safety Behaviors to Eliminate: VOMIT/VOMITING

Many clients will take steps to avoid vomiting, including taking deep or slow calming
breaths, using (or carrying) antiemetic medication, chewing gum, or carrying a water
bottle. Encourage the client to drop these behaviors during exposure and to practice
fear tolerance instead. Other clients will engage in behaviors designed to mitigate the
effects of vomiting, such as carrying bags, being near a trash can, or staying near an
exit. Encourage the elimination of these behaviors.
96 The Big Book of Exposures

Exposures for Fear of Choking

In-Office Exposures: CHOKING

• Listen to an audio recording of people choking. Do an online search for “choking

noises” with your client.

• Look at pictures of people choking. Start by searching online for cartoons of people
choking, and then increase the intensity to looking at pictures of real people choking.

• Watch video or movie clips of people choking. Watch a clip from the movie Mrs.
Doubtfire in which the lead character chokes while eating at a restaurant. You can
also search online for “real choking videos” to see clips of people choking and
receiving the Heimlich maneuver.

• Read online stories about people choking. Search online for stories of people
who have choked on food items.

• Practice rapid swallowing. Have your client target the feared sensation of choking
by rapidly swallowing with nothing in his mouth. This can mimic the sensation of the
throat becoming tense.

• Imaginal exposure to choking. Have the client imagine chewing and swallowing
food that is difficult to swallow, like a large piece of chewy steak. Describe what it
would feel like getting stuck in the throat, as well as the feared consequence (e.g.,
getting the Heimlich maneuver, trying to do the Heimlich over the side of a chair or
table while alone, or dying).

• Combine viewing videos of choking with eating. In session with your client, watch
videos of choking while your client eats a snack of a feared food item.

• Pretend to choke. Have the client grab his throat to make the sign that he is choking
and make gasping noises.

• Hold a non-food item in the mouth. Have your client place a small item in the front
of his mouth (e.g., a water bottle cap, a small plastic toy that has a hazardous
warning to children under three on it).

• Eat foods that tend to make you want to reach for a drink. Have your client eat
a spoonful of peanut butter without drinking anything to help it get down.

• Swallow pills. Have the client swallow an over-the-counter medication (e.g., vitamin
pill, Tylenol) with water. Later, make this more challenging by having the client
swallow a pill without any fluid.

• Work through a food hierarchy. Systematically introduce any specific foods (e.g.,
mozzarella sticks, steak sandwich, hot dogs, grapes) that the client has been avoid-
ing. Start with a bite and gradually increase the amount he eats in session.
Specific Phobia 97

Out-of-Office Exposures: CHOKING

• Swallow food items at home. Have the client practice swallowing small food items
(e.g., tic tacs) at home when in the company of others, then when alone.

• Watch video clips of choking. Have the client view these clips while eating at home
alone.

• Eat feared food items while home alone. Have the client work through a food
fear hierarchy that you and he created in session. Consider including “sharp” foods
like tortilla chips as they can scrape the side of the esophagus and feel uncomfort-
able if the piece was too big.

• Go out to restaurants. Ask the client to go to a restaurant by himself and eat items
that are higher up on the food fear hierarchy.

Safety Behaviors to Eliminate: CHOKING

Eating in the presence of other people is a common safety behavior for clients with fears
of choking (presumably because the other person can administer first aid or call 911 in
case of choking). Encourage the client to practice eating alone.

Many clients with fear of choking severely limit what they eat, often sticking to liquids or
soft foods. Encourage the gradual incorporation of more challenging foods. Some clients
with choking fears will carry a water bottle in case of food getting “stuck.” Encourage
them to leave the water bottle at home. Finally, some clients who fear choking will
overchew food to minimize the perceived risk of choking. Encourage a normal amount of
chewing.
98 The Big Book of Exposures

CONCLUSIONS
Specific phobias can be of the natural environment (e.g., storms); blood, injections, or
injuries; animals (e.g., dogs, snakes, insects); specific situations (e.g., enclosed spaces,
flying); or other situations or activities including vomiting or choking. Specific phobias
are best addressed using in vivo exposure to the feared situation or activity, though in
some cases imaginal or virtual reality exposure can be used. As with all fears, be vigilant
for the presence of safety behaviors and strive to eliminate them wherever possible.
In the next chapter, we will review diagnostic criteria for panic disorder and agora-
phobia and provide both interoceptive and in vivo exposure ideas for addressing these
conditions.

CHAPTER RESOURCES
Reminder: These resources are also available to download and print from http://www.
newharbinger.com/43737.

Example Imaginal Exposure Script—Storms

An ominous green haze covers the sky as the warning alarms in my town begin to
sound. There was not supposed to be a storm today. There is nowhere to run or hide,
as a tornado can change its path at any moment. The alert on my phone comes
through, which increases my heart rate. The tornado is approaching. I must brace
myself immediately. I’m all alone and the most terrified I have ever been in my life.
I frantically search for the safest part in my home where I will least likely be hit by
falling debris. The lights in my home flicker and then suddenly go out. I am in
complete darkness. I hear the pounding rain outside. All of a sudden I hear a loud
noise in the distance that sounds as if it is getting closer. It is as if a freight train is
coming straight for my home. I hide myself fully under a mattress and close my eyes
as I hear the shingles of my roof being ripped off of my home. Things are falling all
around me. I feel the outside air and know I am exposed and no longer safe in my
own home. This is it. This is how it all ends.
Specific Phobia 99

Example Imaginal Exposure Script—Blood

I open the door to the phlebotomist’s office to get my blood drawn and before even
checking in for the appointment I am filled with fear. With no time to even consider
leaving, I hear my name being called. I am seated in a large chair where many before
me have had their blood taken. As soon as that thought crosses my mind, I try to push
it away. I place my arm on the chair, palm side facing up. I can barely get my eyes to
focus while the technician grabs a tourniquet and tightens it around my upper arm.
I am given a squishy ball to hold and asked to clench my fist to help find a good vein.
Sweat beads up on my forehead and my free arm grabs the arm of the chair, bracing
for the worst. I see the needle lying on the table next to a stack of test tubes. Are those
all for me to fill? What if I faint? As if in slow motion, the technician takes a cotton
ball and alcohol to wipe down the area of my arm that the needle will stab. I hear the
cap of the needle fall to the metal table as the tip of the long, silver needle meets my
skin. I feel the sting of the needle and think this must be over soon, but the needle
stays in and more and more vials of blood are collected. I try to focus my eyes on the
notices taped on the concrete wall of the sterile room, but my eyes won’t adjust. The
room starts to spin around me and as I begin to tell the technician I feel sick, I feel my
body begin to go limp.

Example Imaginal Exposure Script—Dentist

I arrive at the dentist’s office and walk inside. It smells sterile and uninviting. I feel a
shiver run through my body. I can hear the drill in the background and know that it
will soon be my turn. I sit in the office in an uncomfortable chair looking around at
all the mini-size freebies of mouthwash, floss, and toothpaste. My hands are shaky
and my mouth dry. The dental hygienist calls my name and brings me back into the
present moment. I follow her to the room to have X-rays taken. Minutes later the
dentist comes in and says, “You’re going to have to have that cavity filled.” He asks me
to open my mouth and try to relax. How can I relax? I grip the sides of the chair and
brace for impact. He’s trying to relax me by talking about summer vacation plans, but
I can’t be distracted. I feel the sting of the Novocain needle. What if it won’t be
enough? What if I feel the drill? What if I need to run out of here crying? As soon as
I am numbed, the dentist grabs the drill and turns it on. The high-pitched sound
makes me cringe. Hot tears start to fall down my face. I’m panicking. This is my worst
fear. I brace myself as I hear the drill touch my tooth. I feel it! I feel it! I don’t have
enough Novocain. I knew this would happen. I raise my hand to gesture for him to
stop. He does. He tells me he will need to give me another shot of Novocain before we
can move forward. He does just that. He drills and drills and drills. The whirling
sound echoes in my ears. Will this ever end?
100 The Big Book of Exposures

Example Imaginal Exposure Script—Snakes

I am sitting outside relaxing on a warm, sunny day when I feel a cold and slimy
sensation touch the back of my ankle. I look down and see a big ugly black and red
snake. I jump back, knocking my glass of iced tea off the table and onto the floor.
The snake is frightened and gets into a menacing stance as if poised to strike. The
snake is about eighteen inches long and has a slender but muscular body. I can’t help
but notice the pink tongue that flashes in and out of its mouth, and every few seconds
I see a piece of its yellowish fang. I feel a flash of panic run through my entire body as
I have the urge to run but am too scared it will chase me—or even worse. I stand
frozen in my spot, scanning my mind for escape options. I reach for a stick in hopes
that I can scare it off when I see movement out of the corner of my eye. There must
be at least three more snakes! They are so close to each other that I cannot see where
one ends and the other begins. I hear a hissing sound as the scaly and menacing
creatures slither toward me. I am paralyzed with fear.

Example Imaginal Exposure Script—Dogs

I decide to take a quick walk on my lunch break, and I see a man across the street
walking his massive dog. The dog appears to be a mixed breed of some sort—maybe
German shepherd and Rottweiler. I can immediately tell it is not friendly. I start
moving faster as I feel my fear increasing. I hear the owner yell from across the street,
“No! No! Stay!” The owner has completely lost control of the dog, which begins
thrashing around and wiggles its neck out from the spiky collar. The dog’s leash and
collar are now lying on the ground by the owner. In an instant, the dog takes off
across the street with his eyes glued to me. I am his target. The dog doesn’t slow as
he approaches me and I am suddenly knocked to the pavement. He snarls at me as
if I am his worst enemy. His big white teeth clench down on my right forearm as I
struggle to hit him with my other hand. There is blood everywhere. The dog’s owner
runs toward us and keeps calling the dog’s name and telling him “No!” but he is
unable to grab the dog without his leash or collar. There is nothing I can do. I am
helpless.
Specific Phobia 101

Example Imaginal Exposure Script—Bugs

I’m lying in my bed, with my eyes closed, and I feel a tingling sensation on my hand.
I open my eyes, and it’s a giant, hairy bug, looking right at me. I feel paralyzed with
fear. I can feel each of its legs on my skin as it crawls over my hand. I don’t want to
look at it, but I’m afraid to look away. My heart is racing and I feel like I can’t
breathe. Slowly I look down toward my feet and I see that there are dozens, maybe
hundreds, of bugs all over me! They’re crawling and slithering over my legs, my
stomach, and my chest. My skin feels like it’s crawling. I’m terrified but I can’t move;
I can’t just get up and shake the bugs off. They’re going to stay on me. I look back to
the big bug on my hand and see that it’s now crawling up my arm, making its way
toward my face. All I can feel are the bugs all over my skin and my own heart
pounding out of my chest. I can hear the bugs clicking and hissing as they crawl on
me. The big bug has made its way up to my face now. I shut my eyes and close my
mouth tightly to prevent the bug from getting in, but it’s headed toward my ear. I think
it’s going to crawl into my ear and possibly lay eggs in there. As the bug crawls into my
ear, the pack of bugs keep making their way up my body until they are covering my
face. I’m trying not to breathe, but I can feel them making their way into my nostrils
and my mouth. I want to scream but I can’t because there are bugs all over my
mouth.

Example Imaginal Exposure Script—Flying

I’m on the plane and I’m already feeling nervous. What if something happens to the
plane? My heart is racing and I wish we would just land already. The pilot comes on
the intercom, and I think I hear him say something about turbulence, but I can’t hear
him very clearly because of all of the people talking. When we hit the first bump, I
immediately grip my armrests. What’s happening? My heart is really pounding now
and I’m feeling very scared. Another bump and now the flight attendant hurries back
to her seat and buckles in. I’m getting more and more scared, feeling like my chest is
going to explode. Now the bumps are coming more rapidly and more strongly. It feels
like we’re hitting things in the air, the way the plane is lurching. The people on board
have become quiet and all I can hear now is the sound of the engines. They sound
like they’re whining, like something’s wrong with them. I look around, panicked, and
see that other people on the plane have fearful faces. One woman is crying. Another
man looks like he’s praying. The plane does a sudden drop and everyone on board
screams. I’m panicking but there’s nothing I can do; I’m strapped in a seat 30,000 feet
in the air. Now the plane drops down again and keeps going. The flight attendant yells
out, “Assume crash position!” Everyone on the plane is screaming now. I put my head
between my legs and I know I’m about to die as we plummet down.
102 The Big Book of Exposures

Example Imaginal Exposure Script—Choking

I’m at home alone eating a sandwich. As I swallow, I feel something is stuck in my
throat. I go to get a glass of water from the kitchen sink, but no water comes out of
the tap. I feel like I can’t breathe. I’m getting really scared and I realize that I’m
choking. In a panic, I open the refrigerator door looking for something to drink but
there’s nothing in there. My throat is full and I can’t swallow, breathe, or talk. I try
pushing on my stomach but that doesn’t help. My face is getting red, and it feels like
there’s a pressure coming from behind my eyes. I’m terrified and I think that I’m
choking to death. There’s no one home to help me. Frantically I look for my phone
to call 911 but I can’t find it. The room seems to be spinning as I’m running out of air.
I drop to my knees, clutching at my throat. I try to scream but no sound comes out.
As I slide to the floor I realize I’m dying.

Rules of the Jelly Bean Game

Your therapist has a mixture of jelly beans for you to try. Some are delicious, like juicy
pear, and some are…not so delicious, like booger.

Goal of the game: Earn as many points as you can to cash them in for a reward (decide
this reward with your therapist/parent/spouse). You will find the points for each pairing
below. Since each gross jelly bean has a yummy counterpart, you will earn the same
amount of points if it turns out to be a “good” jelly bean or a “bad” one. You get the
points for taking a risk and trying it!

Additional directions: In order to get the points for choosing one of the jelly beans
below, you must chew the bean at least three times. No partial points will be awarded.
At any time in the game, you can “steal” a barf jelly bean for an additional 5 points!

We dare you not to vomit!

Jelly Bean Pairs

• Dead Fish—Strawberry Banana Smoothie (1 point)
• Spoiled Milk—Coconut (1 point)
• Stinky Socks—Tutti-Frutti (1 point)
• Lawn Clippings—Lime (1 point)
• Toothpaste—Berry Blue (1 point)
• Rotten Egg—Buttered Popcorn (2 points)
• Canned Dog Food—Chocolate Pudding (2 points)
• Booger—Juicy Pear (2 points)
• Caramel Corn—Moldy Cheese (2 points)
• Barf—Peach (3 points)
Specific Phobia 103

Let’s Go on a Bug Hunt!

Goal: Find as many bugs as you can. Play as a team or against one another to see who
can find the most bugs! Search online for any bugs you do not know the name of so that
you can include the information below.

Bug Type Bug’s Color Bug’s Other Characteristics

Length (e.g., flying, noises it makes)
 CHAPTER 6

Panic Disorder and Agoraphobia

In this chapter, we will discuss exposure therapy for panic disorder and agoraphobia.
After reviewing the criteria of these disorders and important treatment considerations,
we will provide exposure ideas for facing fears of physiological sensations by using intero-
ceptive exposures. We will also include creative in vivo exposure ideas to target the fear
of confined spaces or feeling trapped, crowded areas, and open spaces as is seen in clients
with agoraphobia. Finally, we will provide ideas for imaginal exposure exercises.

WHAT IS PANIC DISORDER?

Nearly 7% of adults in the United States have a lifetime history of panic disorder, and
nearly 4% have a lifetime history of agoraphobia (Kessler et al., 2012). Agoraphobia fre-
quently co-occurs with panic disorder (Kessler et al., 2006); hence, we combine them in
this chapter.
According to the DSM-5 (APA, 2013), the criteria for panic disorder are:

A. Having four or more of the following symptoms during an unexpected panic

attack (defined as “an abrupt surge of intense fear or intense discomfort that
reaches a peak within minutes” [p. 208]):
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Feeling of shortness of breath or of being smothered
5. A feeling of choking
6. Chest pain or discomfort
7. Nausea or stomach distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Chills or hot flashes
10. Numbness or tingling sensations which are usually in the hands, feet, or
face (paresthesias)
106 The Big Book of Exposures

11. Feelings of unreality (derealization) or being detached from the self

(depersonalization)
12. Fear of losing control or going crazy
13. Fear of dying

B. At least one of the attacks has been followed by at least a month of worry
about having a future panic attack or the potential consequences of having
panic attacks, such as having a heart attack, or some change in behavior as an
attempt to avoid having another panic attack.

C. The symptoms are not better accounted for by a medical condition, medication
use, or substance use.

D. The disturbance must not be better explained by another mental health

disorder. For example, panic attacks only occurring in response to feared social
situations (e.g., giving a speech, making small talk) would be better accounted
for by a diagnosis of social anxiety disorder.

Panic Attacks vs. Panic Disorder

Panic attacks are a relatively normal phenomenon that many of us will experience in
our lifetime. It is important to remember that having a panic attack is not the same thing
as having panic disorder. Panic attacks are necessary, but not sufficient, for the diagnosis
of panic disorder. A panic attack is a brief, intense episode of anxiety that can be trig-
gered by something in particular, such as seeing a spider in the case of specific phobia, or
can occur out of the blue, for no apparent reason at all, in unexpected situations.
Individuals with panic disorder, unlike those with panic attacks due to other anxi-
ety-related disorders, experience multiple unexpected panic attacks. They then worry
about when and where the next attack might occur. Due to the fear of future attacks,
individuals with panic disorder may start avoiding situations in which they think there is
a chance of having a panic attack. For example, an individual may have had her first
panic attack while at the grocery store. The person then stops going to the grocery store,
or she goes during times when there are not many people shopping (e.g., late at night or
first thing in the morning). The individual’s fear of the grocery store may begin to gener-
alize to the point where she may then start avoiding other stores, such as shopping malls,
banks, coffee shops, and so on. This is how agoraphobia (see below) can develop.

Is Panic Dangerous?
Despite the fact that panic attacks are extremely uncomfortable, it is important for
the client (and the therapist) to recognize that they are not dangerous. People with panic
disorder may present to the emergency room thinking that they are having a heart attack
Panic Disorder and Agoraphobia 107

or some other serious medical emergency. This is often because the symptoms of panic,
such as heart racing or pounding, lightheadedness, and tingling sensations, are misinter-
preted as catastrophic in nature (i.e., that they are symptoms of a heart attack). The goal
of exposure treatment is not to escape the uncomfortable physiological sensations and to
make sure they never occur again, but rather to face them, experience them, and help the
client to recognize that they are harmless.

WHAT IS AGORAPHOBIA?
The criteria for agoraphobia listed in the DSM-5 (APA, 2013) are:

A. Significant fear of at least two of the following situations:

1. Using public transportation, such as planes, trains, subways, or buses
2. Being in open spaces, such as parking lots or bridges
3. Being in enclosed spaces, such as shops or theaters
4. Standing in line or being in a crowd
5. Being outside of the home alone

B. The individual avoids the above situations due to fear that escape may be
challenging and/or help might not be readily available should panic-like or
embarrassing symptoms arise, such as incontinence or vomiting.

C. These situations must almost always provoke fear or anxiety.

D. The situations are either actively avoided or endured with intense anxiety or
discomfort and may require the presence of a companion, such as a parent or
spouse.

E. Fear or anxiety is out of proportion to actual threat or danger.

F. Fear, anxiety, or avoidance is persistent and lasts six months or more.

G. Fear, anxiety, or avoidance must cause significant distress or interference in

important areas of functioning.

H. Should a medical condition be present (e.g., irritable bowel syndrome,

Parkinson’s disease), the fear, anxiety, or avoidance must be excessive.

I. Fear, anxiety, or avoidance is not better accounted for by another psychiatric

disorder, such as a specific phobia or social anxiety disorder.
108 The Big Book of Exposures

PANIC DISORDER AND AGORAPHOBIA:

CLINICAL CONSIDERATIONS
In this section, we will discuss issues pertinent to both panic disorder and agoraphobia,
either combined (most common) or in isolation.

Fear and Avoidance in Panic Disorder and Agoraphobia

It is easy to miss the core fear in panic disorder and agoraphobia. Individuals with
these disorders commonly come to treatment describing a fear of external stimuli—for
example, clients describe a fear of driving in traffic, a fear of crowded shopping malls, and
so on. And while it is certainly true that these situations are often feared and avoided,
they are not the core fear. At their heart, panic disorder and agoraphobia represent a fear
of fear (Goldstein & Chambless, 1978). Individuals with panic disorder and agoraphobia
are fundamentally afraid of their own physiological fear reactions, and what they think
those reactions signify. Clients may believe, for example, that:
• Racing heart means I am going to have a heart attack.
• Dizziness means I am going to pass out.
• Upset stomach means I am going to throw up.
• Derealization means I am going crazy.
• Various other signs or symptoms of the “fight-flight-freeze” response mean I am
going to panic and lose control of myself.

When we conceptualize panic and agoraphobia as a fear of fear, these disorders

become much easier to understand. Panic attacks, though they may be unexpected, do
not come from nowhere. Rather, the cycle (see our CBT triangle figure in chapter 1)
begins with an uncomfortable but benign physiological sensation, such as elevated heart
rate or butterflies in the stomach. The person then engages in distorted patterns of
thinking such as probability overestimation (e.g., I am going to have a heart attack) or cata-
strophizing (e.g., If I experience a panic attack, it means I will run amok like a crazy person and
have to be hospitalized). These cognitive distortions, in turn, lead the person to feel even
more fearful, and around and around it goes, often culminating in a panic attack (Clark,
1986).
The person’s behavioral response to this “fear of fear” pattern, not surprisingly, is
often one of avoidance. People with agoraphobia will often avoid situations in which
escape would be difficult or help would not be immediately available in case of a panic
attack or panic-like symptoms. So, for example, a client who fears having a panic attack
might avoid going to crowded places (such as a shopping mall), driving in heavy traffic,
or being far away from home, in case she feels panicky and won’t be able to escape easily
or get help from others.
Panic Disorder and Agoraphobia 109

The avoidance in panic and agoraphobia can also be of internal stimuli (i.e., avoid-
ance of feelings and physiological sensations). Because of their fear of fear, many clients
with panic and agoraphobia will avoid activities that stimulate physiological arousal.
This can include avoidance of exercise, avoidance of scary movies, avoidance of caffeine,
avoidance of sex, and avoidance of strong emotions. In each case, the individual is trying
to keep her physiological arousal level low in the hopes that this will reduce or eliminate
the perceived risk of disastrous consequences.
Finally, we should note that individuals with panic and agoraphobia very frequently
use a variety of safety behaviors that, while soothing, can be counterproductive. Clients
may be reluctant to leave home without a bottle of benzodiazepines, a cell phone, a bottle
of water, or some other “crutch.” In many cases, that “crutch” is another person; for
example, a client might be willing to go to the mall only in the presence of her spouse
because of the mistaken belief that the spouse will “rescue” her from the situation in the
event of a panic attack or panic-like symptoms.

Important Considerations in the Treatment of

Panic Disorder and Agoraphobia
The avoidant behavior in agoraphobia can resemble that of specific phobia (see
chapter 5). For example, clients with either condition might avoid certain situations such
as flying in an airplane. The critical difference is what is feared. The client with a specific
(flying) phobia generally fears that the plane is going to crash, whereas the client with
agoraphobia fears that she will have a panic attack or panic-like symptoms and will not
be able to escape while on the plane or will become embarrassed. This distinction has
important implications that go beyond the diagnostic label. When a client is afraid of
plane crashes, we might be well advised to use in vivo exposure to air travel when pos-
sible, or perhaps imaginal exposure or VRET that relates specifically to being on an air-
plane. However, when a client is afraid of fear, panic, and panic-like symptoms, it is
critical to also include interoceptive exposure so that you can expose the client to the
fearful sensations themselves.

Involving a Safety Person in Treatment

As we have mentioned, agoraphobia is a fear of being trapped or stuck in a place
where escape may not be easy or help might not be available, and the individual fears her
own fearful emotions and bodily sensations. For example, the client may fear becoming
nauseated and throwing up while in a crowded place where she may not be able to escape
easily, such as a packed movie theater, thus becoming embarrassed. Sometimes, an indi-
vidual with such a concern may be less anxious (and more willing to enter feared situa-
tions) in the presence of a “safety person.” A safety person might include a spouse, parent,
friend, or other trusted companion. This person might accompany the client in only very
high stress situations, such as flying or going long distances away from home, or the
110 The Big Book of Exposures

relationship can evolve to the point where the client goes very few places (or no places at
all) without the safety person.
This safety behavior of bringing a trusted companion with the client is an important
target for treatment, as you will want to work with your client to have her gain the con-
fidence to enter feared situations alone. Therefore, we recommend including the safety
person in the client’s treatment, with the client’s permission. You may ask your client to
bring her safety person to early sessions to join in exposures with the goal of eventually
having the client do exposures on her own, without being accompanied by the safety
person. The safety person will also benefit from psychoeducation to understand the role
of avoidance and safety behaviors, and how you are working with your client to system-
atically eliminate the avoidance behaviors.

BEHAVIORAL TREATMENT FOR PANIC

DISORDER AND AGORAPHOBIA
Although panic disorder can occur with or without agoraphobia, these two disorders
frequently co-occur (Grant et al., 2006; Kessler et al., 2006) and have a common core
mechanism (fear of fear). Thus, we have combined our discussion of exposures for these
two overlapping disorders in this chapter. We have organized this chapter according to
the three types of exposure that we discussed in chapter 3:
1. Interoceptive exposures
2. In vivo exposures
3. Imaginal exposures

Interoceptive Exposures
Chapter 3 will be a handy resource when working with your clients with panic and/
or agoraphobia as it includes additional information on how to do interoceptive expo-
sures, which are a major part of the treatment for panic and agoraphobia. Chapter 3 also
includes worksheets that will be useful to you, so we suggest reviewing that section. Some
clinicians might be uncomfortable doing and prescribing interoceptive exposures with
clients who have panic disorder. After all, as clinicians, we want our clients to feel better,
and interoceptive exposures can definitely make them feel worse (at least in the short
term), which is normal when conducting any kind of exposure. However, the importance
of interoceptive exposure in panic and agoraphobia cannot be overstated: we consider it
to be the central feature of CBT for these conditions.
This is a time when that sneaky exposophobia may begin telling you that interocep-
tive exposure is a risky intervention that should be avoided. First, don’t avoid. Second, go
ahead and do some practicing on your own! We recommend practicing doing all of the
interoceptive exposures first by yourself before asking your clients to do them. This way
Panic Disorder and Agoraphobia 111

you’ll get the hang of them, realize they are not as bad as you might imagine, and feel
more confident prescribing the interventions in session and for homework. They will feel
uncomfortable, but check in after the exercise and ask yourself if it was really as cata-
strophic as you thought it might be.
We have included a medical clearance form at the end of the chapter for you to send
to your clients’ primary care physicians for approval, which can be helpful if a client has
a physical condition you are concerned about prior to starting interoceptive exposures.
The exposure exercises listed on the form are the ones most commonly used in panic and
agoraphobia treatment. We have also left two blank spots on the form for you to fill in
with other exposures you may be using from our ideas throughout this chapter.

In-Office Exposures: INTEROCEPTIVE EXPOSURES

• Get hot. Ask the client to put on several layers including big winter coats, or to sit
near a heater or space heater in a small room, to create a sensation of being over-
heated. This exposure may create other feared sensations as well, such as a feeling
of suffocation.

• Hyperventilate. Model for the client how to hyperventilate before having your
client do this exposure. This involves taking in deep and fast breaths through the
mouth and pushing the air back out quickly and forcefully, as if blowing up a large
balloon. Have your client do this for one minute.

• Breathe through a small straw. Ask your client to breathe through a coffee stirrer
or cocktail straw while holding her nose so that there is limited air coming in and out,
making it feel as though it is challenging to breathe well. Have the client try to do
this exercise for about one minute or longer.

• Get dizzy. There are several ways to induce feelings of dizziness. You can ask your
client to stand up in the center of the room and start spinning in circles, or she can
sit in an office chair that swivels and spin around while in the chair for one minute.
You can also ask your client to repeatedly roll her head from side to side for thirty
seconds, which can be dizzying.

• Get up quickly. Ask your client to sit in a chair and bend forward so her head is
near the ground. Have the client stay there for thirty seconds to a minute and then
sit up quickly, which can send a rushing feeling to the head.

• Increase heart rate. Ask your client to jog in place or repeatedly go up and down
a set of stairs for one minute to increase her heart rate.

• Feel disoriented. Ask your client to wear someone else’s prescription glasses to
mimic things looking disoriented and fuzzy.
112 The Big Book of Exposures

• Mimic derealization. Since clients will report a feeling of derealization when expe-
riencing panic, it is helpful to recreate that sensation as part of interoceptive expo-
sure exercises. We recommend purchasing a strobe light to use in a dark room with
your client. You can have the client first practice sitting in the room silently while the
strobe light is running, and then later practice having a conversation or doing a
routine activity while the light is on so she can learn to continue with routine activities
despite feeling anxious. Exposure to flashing lights may be contraindicated in a
small percentage of the population, including those who are prone to seizures. You
can discuss this with your client prior to beginning the exposure.

• Have a dry mouth. Ask your client to put a cotton ball in her mouth to remove saliva
and to induce a feeling of dry mouth, which can happen while nervous or
panicking.

• Get tripped out. Do an online search for “trippy moving circles” or “rotating spirals.”
Have the client stare at the circles for at least one minute. There are also websites
that allow the individual to look at spinning circles followed by pictures of scenes,
such as outer space. If the client views the outer space scene (for example) following
staring at the moving circles, the outer space scene appears to be moving.

• Stare at a light. Ask your client to stare at a fluorescent light in the office for thirty
seconds to a minute and then look away and try to read something, such as a maga-
zine or book, which can induce a feeling of derealization.

• Get caffeinated. Ask your client to bring a coffee or energy drink with her to
session and drink it in a short period of time to feel the effects of the drink.

• Wear a constricting article of clothing. Some clients fear getting stomachaches or

feeling stomach discomfort. Ask your client to wear a tight belt around the stomach
to mimic that uncomfortable sensation. For those who fear the sensation of suffocat-
ing or tightness in the throat, you can ask your client to wear a tight scarf around the
neck to mimic this sensation.

• Place a book on the chest. Ask your client to lie down and place a heavy book on
the chest to mimic the sensation of not being able to breathe deeply and freely.

• Create a nausea jar. Make a jar with your client of things that smell nasty to her
and would create a feeling of nausea, such as cigarette butts, moldy food, or dog
poop.

• Get tense. Ask your client to hold a push-up position for one minute or as long as
possible to mimic the sensation of weak muscles following the feeling of being tense.

• Tense the throat. Ask your client to tense her throat in a “mid-swallow” position to
induce a feeling of tightness.
Panic Disorder and Agoraphobia 113

Out-of-Office Exposures: INTEROCEPTIVE EXPOSURES

• Get caffeinated while in scary places. Ask your client to drink an energy drink,
coffee, or espresso while in a place that is triggering for her panic or agoraphobia,
such as while driving or in a crowded store.

• Hyperventilate. Ask your client to hyperventilate before entering feared situations,

such as a mall or driving, to mimic panic sensations and practice riding out the
anxiety out while continuing to engage in everyday activities.

• Feel uncomfortable in the real world. Ask your client to practice any of the above
interoceptive exposures in real-life scenarios, meaning out of the therapy office.
Examples of places to go with the client (or to send her for homework) include the
grocery store, the place where she had the first (or scariest) panic attack, work,
elevators, or any other feared situations. If you both choose to go to a grocery store,
for example, you can sit in the car with the client and have her repeatedly practice
these interoceptive exercises and then walk directly into the grocery store. You can
also ask her to do some of these within the grocery store.

Safety Behaviors to Eliminate: INTEROCEPTIVE EXPOSURES

During interoceptive exposures, you want to the client to be fully engaged in the exer-
cise without doing anything to feel safer, such as hyperventilating at a slower pace than
you have asked or spinning around slowly. The client may start out strong and then begin
to fade the intensity; keep an eye out for this and remind her to pick up the pace. You
can even use a metronome or have the client copy your speed in doing the exercise if
she has a tendency to “cheat.”

When doing interoceptive exposures, we recommend not having the client first know how
long she is going to be doing an exercise, as being focused on the clock or counting
down the time in her head can become a safety behavior. Use your watch, phone timer,
or clock to keep track of the length of the interoceptive exposure exercise without giving
the client this information.

Some clients who fear becoming sick will later tell you that they didn’t eat or drink prior
to coming into the interoceptive exposure session for fear of getting sick. Remind them
to keep their dietary routine as normal as possible before coming to therapy, and if
there is a snack available and some water, have the client eat or drink before doing the
exposure to eliminate the safety behaviors.
114 The Big Book of Exposures

In Vivo Exposures
As discussed in chapter 3, in vivo exposures consist of directly confronting feared
situations in real life, as opposed to imagining them. These exposures can be conducted
in the office, conducted out of the therapy office with your client, and/or assigned to your
client for homework.
Because agoraphobia has a substantial overlap with claustrophobia (in both cases,
clients are afraid of becoming trapped and unable to escape), we recommend you review
the “Tight Spaces” in vivo exposures in chapter 5. Many can be useful for clients with
agoraphobia as well.

In-Office Exposures: IN VIVO EXPOSURES

• Say catastrophic thoughts aloud. Have your client say aloud feared thoughts that
are common among those with panic disorder, such as “I am going to suffocate,” “I’m
losing control,” or “I will pass out and be embarrassed.”

• Get locked up. Lock the client in an area of the therapy office (e.g., closet, court-
yard) to target a fear of being “trapped.”

• Limit personal space. With your client’s permission, invite colleagues or trainees
into the session and have them stand close to and around the client, or have them
also stand in front of the door so that the client does not feel there is an easy way
out.
Panic Disorder and Agoraphobia 115

Out-of-Office Exposures: IN VIVO EXPOSURES

• Go someplace new. Give the client directions to a location she has never been to
before and have her go there for “homework” without the use of any safety
behaviors.

• Sit in the middle of a row. Have your client go to a crowded theater, place of
worship, or other venue and sit in the middle of the row rather than on the aisle.

• Wait in line. Ask the client to wait in line in a store, bank, or coffee shop to target
the fear of being in a line. When this becomes easier, ask the client to always
choose the longest line at a grocery store or other location.

• Sit in traffic. Ask your client to purposefully take a drive during rush hour, regard-
less of whether she has someplace to go. When the client has multiple route options
for how to get to work or another necessary location, ask her to look up the current
traffic time for all routes and to choose the busiest one.

• Take a shopping trip. Ask your client to go shopping in a mall during peak hours.

• Take public transportation. Ask your client to systematically practice riding a bus,
subway, or train. Have her start small by going only one stop on the bus or other
form of transportation and work up to taking longer trips. Later, you can combine
this in vivo exposure with listening to an imaginal exposure script over headphones
while on public transportation.

• Get lost. Have the client drive you to a location that she is unfamiliar with and that
is off the beaten path. Then get out of the car and into either a cab, Uber or Lyft,
or the car of a colleague who has been following you, and have the client drive
back alone.

Safety Behaviors to Eliminate: IN VIVO EXPOSURES

Clients with panic disorder and/or agoraphobia may attempt to go to stores or malls
during off hours so that they can escape easily if panic-like or embarrassing symptoms
arise. This safety behavior should be eliminated as soon as possible. If the client is
unable to stop altogether at first, then you can gradually reduce these behaviors. For
example, if the client goes to the grocery store only in the early morning because it is
less busy, then work toward the goal of getting her to go at 5:00 p.m. after people are
getting out of work, or on the weekends. The client may not be ready for this change all
at once, so you can arrange for her to try going at lunch time, then at 3:00 one day, then
at 4:00, and so on.
116 The Big Book of Exposures

Imaginal Exposures
For feared consequences in which in vivo exposure is not practical, such as when a
client with panic and agoraphobia fears throwing up in public, you can use imaginal
exposure. As you may remember from chapter 3, imaginal exposure involves creating a
story either on paper or on a computer that the client will read aloud (or record on a
phone or computer and listen to) repeatedly. You will work with the client to include
vivid details that should involve all of the five senses. (See the guidelines in chapter 3 for
setting up successful imaginal exposure scripts; we also provide you with an example
script at the end of this chapter.)

In-Office Exposures: IMAGINAL EXPOSURES

• Write an imaginal exposure script. Ask your client to write a script about her worst
fears related to panic or agoraphobia. (See the example imaginal exposure script
at the end of this chapter.) Encourage your client to make a recording of the script
so that she can listen to it outside of session or when pairing it with other exposures,
such as taking a drive.

• Read an imaginal exposure script while looking at pictures. Ask the client to
recite or listen to her imaginal exposure script while simultaneously looking at pic-
tures of tight spaces, wide open spaces, or other feared situations.

Out-of-Office Exposure: IMAGINAL EXPOSURES

• Read or listen to the imaginal exposure script outside of session. Many times
the imaginal exposure script ends up having the most impact when the client pairs it
with doing an in vivo exposure (see earlier lists in this chapter).

Safety Behaviors to Eliminate: IMAGINAL EXPOSURES

Clients may be inclined to leave out their worst fears and/or very descriptive details
while writing the imaginal exposure script. Make sure you are checking in with your client
to make sure this is not the case, and if it is, have the client add these details.
Panic Disorder and Agoraphobia 117

CONCLUSIONS
In this chapter we differentiated between panic attacks and panic disorder and discussed
how significant avoidance leads to agoraphobia. We also highlighted the differences
between specific phobias and panic/agoraphobia—an important distinction. In vivo,
imaginal, and interoceptive exposures are all central components to the treatment of
panic disorder. We recommend doing all three of them in your work with your clients. As
a concluding message, remember to fight exposophobia and not avoid interoceptive work,
one of the most critical interventions in the treatment of panic and agoraphobia.
In the next chapter, we will outline the diagnostic criteria for social anxiety and
provide you with helpful and creative behavioral interventions to treat it.

CHAPTER RESOURCES
Reminder: These resources are also available to download and print from http://www.
newharbinger.com/43737.
118 The Big Book of Exposures

Medical Clearance Form

Patient Name:                Date of Birth: 

Your patient is currently engaged in cognitive behavioral therapy (CBT) for anxiety. The
primary aim of this treatment is to reduce patients’ fear of normal physical sensations
(e.g., heart racing, hyperventilation, dizziness) and to reduce their avoidance of feared
situations and sensations that are often present in anxiety and related disorders. It is
possible that some exercises and exposures to feared situations may not be appropriate
for all patients. Therefore, since this patient is under your medical care, please provide
your professional opinion regarding the appropriateness of each of the following exer-
cises the patient may be asked to try in therapy. For each item, please check “yes” if this
patient is medically cleared to engage in this task or “no” if you do not believe this task
is appropriate for the patient, given the patient’s current medical status. Thank you.

Task Description Medically Cleared?

Yes No
  1. Shake head from side to side for 30 seconds
  2. Climb stairs for 1 minute or until feel heart beating quickly
  3. Jog in place for 1 minute
  4. Hold breath for 45 seconds or as long as able to
  5. Tense body muscles for 1 minute
  6. Hold a push-up position for 1 minute
  7. Spin in place for 1 minute
  8. Voluntarily hyperventilate for 1 minute
  9. Breathe through a thin straw for 1 minute
10. Stare intensely at a spot on the wall for 2 minutes
11. (Other) 
12. (Other) 

Your Name (printed):

Signature:

Date:
Panic Disorder and Agoraphobia 119

Example Imaginal Exposure Script—Panic and Agoraphobia

My new boyfriend has been begging me to go to the movie theater with him to see a
new movie on opening night. I can’t. I just can’t. Even thinking about it my hands are
sweaty, my stomach is in knots, and I feel dizzy. I know I am supposed to face my
fear, so with some encouragement I decide to go. As we get out of the car to walk up
to the theater, I can immediately see the long lines that have begun to form to get the
tickets. We stand in line with people in front of me, behind me, and all around me.
I’m starting to shake and my stomach hurts. The smell of popcorn in the air is making
me sick. I feel the nausea rising and I think, What if I get sick in front of all these
people? I know how embarrassing it will be but I try to dismiss the thoughts.
Eventually, we make it into the theater. I attempt to rush ahead of the crowd in
hopes of getting an aisle seat so I won’t be trapped in the middle of the crowd. There
are none. The room is already packed. We spot two seats in the middle of an aisle
down front. How will I get up and run to the bathroom if I am going to be sick? My
hands shake, palms now dripping, and I can barely focus on what my boyfriend is
saying to me. I feel disoriented and not myself and the nausea begins to climb. As the
lights dim and the movie starts, I try to focus but I can’t. All of a sudden, I feel acid in
my throat, and I know I will soon be sick. I will never make it out. I have to climb
over all these people. I jump up and start pushing past people with vomit building in
my throat. Just as I climb over the last person, I vomit all over the floor. Everyone is
looking at me, some are laughing, and some are seriously grossed out. I am
humiliated.
 CHAPTER 7

Social Anxiety Disorder

In this chapter, we discuss diagnostic criteria and important considerations regarding

social anxiety disorder, followed by exposure ideas related to fear of performance situa-
tions such as public speaking, being observed, and using public bathrooms. We also
tackle ways to expose clients to more general social anxiety fears such as meeting new
people, starting and maintaining conversations, being embarrassed, and having others
observe signs that they may be anxious, such as blushing or sweating.

WHAT IS SOCIAL ANXIETY DISORDER?

Eleven percent of adults and adolescents have a lifetime history of social anxiety disorder
(also called social phobia; Kessler et al., 2012). The DSM-5 (APA, 2013) outlines the fol-
lowing criteria for social anxiety disorder:

A. A marked fear of social situations in which the person is exposed to possible

social scrutiny.

B. The person fears he or she will act in a way that causes embarrassment or
negative judgment by others, or that he or she will show anxiety symptoms
that lead to embarrassment or negative social evaluation.

C. The feared social situations almost always elicit fear.

D. The feared social situations are either avoided or are endured with intense fear.

E. The fear is out of proportion to the actual threat or the sociocultural context.

F. The fear is persistent (e.g., six months or more).

G. The fear or avoidance causes significant distress or impairment in functioning.

H. The fear or anxiety is not related to the physiological effects of a medication,

substance, or other medical condition.

I. The fear or anxiety is not explained by another mental health disorder, such as
an autism spectrum disorder or panic disorder.
122 The Big Book of Exposures

J. Should another medical condition be present, such as Parkinson’s Disease, the

fear and anxiety related to social situations must be clearly unrelated to the
medical condition or be excessive in nature.

Fear and Avoidance in Social Anxiety Disorder

The fears in social anxiety disorder can be very specific, such as a fear of engaging in
public speaking, or they can be more generalized, in which daily interactions with others
are highly anxiety provoking. Individuals with social anxiety often worry that their
anxiety will be apparent to others (e.g., that others will see them blush, sweat, or shake)
and that they will be judged negatively for appearing anxious. For example, someone
with social anxiety may fear going to a cafeteria out of concern that he will drop the tray
on the ground, which will cause everyone to look and laugh. Someone else with this fear
may worry about stuttering through a presentation in class and everyone in the school
laughing or gossiping about what happened. People with social anxiety disorder typically
avoid feared situations like these when possible, or endure them with significant distress
(and often safety behaviors) if they cannot be avoided. So, for example, the individual
who fears dropping his tray at the cafeteria might avoid going to the cafeteria, opting
instead to bring lunch from home. The student who is afraid of presentations may spend
the class time hiding out in the bathroom or playing “hooky” from school.

Important Considerations in the Treatment of Social

Anxiety Disorder
It is important to note that some individuals with social anxiety have social skill
deficits. These deficits can result from going years without having real-life exposure to
conversations, attending parties, or speaking in classes, which can lead the individual to
fall behind in mastering normative social skills. Therefore, a subset of clients will benefit
greatly from social skills training in addition to exposure. Briefly, social skills training
involves identifying problems in both verbal and nonverbal aspects of social behavior,
and then role-playing social situations using the following steps:
• Giving direct instructions about the social skill (e.g., “I’d like you to try increas-
ing your eye contact.”)
• Modeling the appropriate social skill (e.g., taking the client’s place in the role-
play while demonstrating appropriate eye contact)
• Having the client practice (e.g., doing the role-play while you monitor the cli-
ent’s eye contact)
• Giving direct feedback (e.g., about strengths and weaknesses in eye contact or
other verbal or nonverbal aspects of social behavior)
• Repeating as needed
Social Anxiety Disorder 123

Another important consideration is that social anxiety can create significant inter-
ference in everyday life, with negative effects on various activities at school or work, such
as communicating with others, giving presentations, participating in discussions or meet-
ings, and forming and maintaining relationships with others. Individuals with social
anxiety may try to control their anxiety by self-medicating with alcohol or drugs as a
means of avoidance. We recommend you assess this carefully prior to beginning treat-
ment for social anxiety disorder.

BEHAVIORAL TREATMENT FOR SOCIAL

ANXIETY DISORDER
In this chapter, we have divided the in-office and out-of-office exposure ideas for social
anxiety disorder into the following categories:
1. Performance-related fears
a. Being the center of attention (e.g., giving a speech)
b. Using public restrooms
2. Fear related to social situations
3. Fear of embarrassment
a. Embarrassing one’s self
b. Appearing anxious to others

While we provide lists of exposures in this chapter to help your client face his fears
related to social situations, performances, using public restrooms, and being embarrassed,
it will be important (as always) for you to look for any other factors that contribute to the
client’s fear in given situations. You can then incorporate these factors into any exposure
to make it either more or less challenging, such as talking to individuals of the same sex
or different sex, same age or different age, one person or multiple people, and so on. Since
the client with social anxiety often fears doing things around others, it can be helpful to
gather confederates (such as colleagues or students), when available, to be part of expo-
sures. We recognize that this might not be feasible for many providers in independent
practice. Therefore, consider going outside of the office to stores or other places where
you can have your client practice interacting with others. We also provide a variety of
imaginal exposure scripts for you to use with your client as templates, which you can
modify in order to target your client’s idiosyncratic fears effectively.

Performance-Related Fears
There are two main categories of performance-related fears experienced by people
with social anxiety disorder: fears of being the center of attention and fears of using
124 The Big Book of Exposures

public restrooms. The first category consists of a fear of doing something in front of
others where the individual is the center of attention, such as giving a presentation or
speech, or being on stage. For many (though not all) clients, it is scarier to be observed
by a group than by an individual. In such cases, although it will be useful to have the
client present or give a speech to you, it will eventually be helpful for him to do those
same exposures in front of larger crowds. If you work in a setting where you do not have
the option of including others in the exposure, you can ask your client to bring family
members or friends to exposures so that he has a larger audience. Consider investing in
virtual reality (VR) equipment, as some programs come with “virtual audiences” for
giving speeches or being interviewed for a job.
Fears of using public restrooms in social anxiety disorder usually take one of two
forms. The first, sometimes called “shy bladder syndrome,” reflects a real or perceived
inability to urinate around other people who are also using the restroom. Clients with
this fear are concerned that others will hear that they aren’t urinating and judge them
negatively for this. These concerns lead to feelings of anxiety and associated physiologi-
cal arousal, which can actually tighten the urethral sphincter and make it more difficult
to urinate, thus creating a vicious cycle. The second form of public restroom fears reflects
concerns that one will make disgusting noises due to urination, flatulence, or defecation
and that others will hear these noises.
Below we provide exposures for both types of social anxiety disorder.
Social Anxiety Disorder 125

Exposures for Fear of Performing/

Being the Center of Attention

In-Office Exposures: PERFORMING/BEING THE CENTER OF ATTENTION

• Use imaginal exposure. Write a detailed imaginal exposure script of either per-
forming in a show or giving a speech in front of a large group, and it not going well.
(See the example script at the end of the chapter.)

• Use virtual reality. Use VR equipment so that your client has an “audience” to
perform to. With some VR equipment, you can upload an actual speech or presen-
tation that the client needs to give in real life, which can be helpful to target anxiety
around an upcoming presentation or talk at work, at school, or in some other area
of the client’s life.

• Present on a well-known or easy topic. Ask your client to begin by giving a one-
minute presentation to you alone, and then make the exposure more challenging by
increasing the time to five and then ten minutes. The presentation can be on any
topic that the two of you choose (e.g., vacations, favorite movies or television shows).
You can also ask the client to bring in prepared school or work presentations to use.
The client can use slides during the presentation at first, but when that no longer
elicits marked fear, you can ask your client to present by memory to make the expo-
sure more challenging.

• Present on a challenging topic. Give the client a topic to prepare a presentation

on for an upcoming session. Assigning a topic that you know a lot about can be
particularly challenging because it also targets the client’s fear of presenting when
not knowing as much as the “audience.” You can give the client feedback following
the presentation, and you can also make it harder by having the audience give
some harsh feedback (having discussed this in advance with the client). For example,
you or other audience members can say, “That really wasn’t a good presentation”
or “I’m surprised that you didn’t seem to put much work into your talk.”

• Have a debate. Set up a mock debate on a controversial topic, such as the death
penalty or abortion. You can bring in confederates (e.g., colleagues or students) to
the debate to make the exposure more advanced.

• Create a mock job interview. Practice having your client do a job interview with
you or a colleague. To make this more realistic, you can ask your client to dress up
for the “interview.” You can also have the client sit in your waiting room and then go
out and bring him back to your office as if it were a true interview. Go through
126 The Big Book of Exposures

several questions with the client, such as “What are your strengths and weaknesses?”
“When was a time there was conflict with a colleague, and how it was resolved?” “Is
there anything else you think may be pertinent?” Give feedback at the end of the
interview so that he can work to improve certain areas.

• Brag to others. Ask your client to prepare a talk called “My Personal Strengths”
and to give several examples of times in which he has really excelled. People with
social anxiety often do not like to talk about themselves or to bring attention to
themselves in any way, which is why this can be a particularly helpful exposure.

• Put on a show. Bring your client outside of the office into a waiting room or parking
lot and ask him to sing a song (e.g., “Twinkle, Twinkle, Little Star,” “Santa Claus Is
Coming to Town,” or any song of his choosing).

• Give a speech to an uninterested audience. Ask your client to give a speech or

presentation while you (and confederates, such as colleagues or students, if possi-
ble) look bored, play on your phones, and roll your eyes at information that the
client provides. The audience of confederates can then ask the client questions,
starting with easy ones and then increasing the difficulty level (e.g., “What research
can you cite that supports your point on X?”).

• Make mistakes on purpose. Ask your client to give a speech or presentation while
making mistakes on purpose. There can be spelling errors on the slides, or he can
plan to mispronounce words or even give incorrect information to the audience on
purpose (without telling the audience these mistakes are deliberate, of course).

• Create an online video. Encourage your client to post an audition tape, speech,
poem, or song online (e.g., Facebook, Instagram, YouTube, SoundCloud) to draw
attention to the performance.
Social Anxiety Disorder 127

Out-of-Office Exposures: PERFORMING/BEING THE CENTER OF ATTENTION

• Be on stage. Visit an auditorium or other setting with a stage. Have the client stand
on stage without an audience to get used to the environment. Then have the client
start a speech or a monologue with no one in the room but you. If possible, gradu-
ally add more people to the room to create a bigger audience.

• Volunteer to perform. Ask your client to volunteer to give a presentation, make an

announcement at a meeting, or do a reading in a church or other place of worship.

• Join Toastmasters. Go online to find a nearby Toastmasters meeting group for

your client to join. Toastmasters is a group that allows individuals to practice speak-
ing in front of others to gain confidence in doing so. The client will also get tips for
improving his public speaking skills. You can start by having your client sign up and
go to a meeting without participating as a beginning step of the process. For some
clients, just signing up and attending can be a valuable exposure!

• Go on a job interview. Whether or not the client is looking for a job, he can prac-
tice interviewing for jobs.

• Sing karaoke. Have your client go to a karaoke bar and sing a song on stage with
a supportive family member or friend. Later, you can encourage your client to get
on stage alone at a karaoke bar. Ask the client to sing a well-known song at first
and then later possibly perform something a little more dated or bizarre that an
audience might not like as much.

Safety Behaviors to Eliminate: PERFORMING/BEING THE CENTER

OF ATTENTION

Clients may tend to overrehearse their presentations, speeches, or other performances.

Help them reduce these behaviors systematically. You can ask them to give “off the cuff”
presentations so that there is little time to rehearse. You can also have them set a time
for how long they will be allowed to prepare their work for the exposure (or real-life
situation).

Individuals with social anxiety often attempt to avoid eye contact with others. Have your
client practice making eye contact with you, and then increase the length of the eye
contact. Encourage the client to begin practicing increasing eye contact in everyday life
as well.

Encourage your client to refrain from looking down or looking at notes excessively during
an exposure by setting goals as to how many times he will look up during the
exposure.
128 The Big Book of Exposures

Exposures for Fear of Using Public Restrooms

In-Office Exposures: USING PUBLIC RESTROOMS

• Use the bathroom with someone standing outside. You or a confederate (a

trainee or colleague) can stand outside of the bathroom door while the client uses
the restroom. Progress to having the helper knock on the door and ask questions
such as “Is anyone in there?”

• Practice non-urination with someone standing outside. Many clients fear that
they will be unable to urinate in a public bathroom, and that this failure to urinate
will be noticed (by the silence) and judged negatively by others. With a helper
outside the bathroom door, have the client practice standing at or sitting on the
toilet and not urinating. Advance to having the helper knock on the door and ask
questions such as “Why aren’t you peeing?”

• Make flatulence sounds with someone standing outside. Some clients fear using
public bathrooms because of a concern that they will make unflattering noises. Have
the client mimic these noises by making flatulence sounds with his mouth. Progress to
having the helper knock on the door and ask questions such as “What was that
noise?”

• Make an announcement about going to the bathroom. Ask your client to

announce to people that he or she needs to go to the bathroom and then to go
directly next to someone using a urinal or stall even if others farther away are free.
Make the exposure more challenging by having the client pour a water bottle filled
with water into the toilet and then say, “Boy, did I have to go!”
Social Anxiety Disorder 129

Out-of-Office Exposures: USING PUBLIC RESTROOMS

• Use a public restroom. Have the client identify public restrooms that have varying
levels of traffic (e.g., a public library might have a small number of people, whereas
a train station might have many more people). For men, have the client practice
using both stalls and urinals.

• Practice non-urination at urinals. Because clients fear that others will notice that
they aren’t urinating, the key is to expose them to the potential embarrassment of
non-urination. Try to identify urinals with varying threat levels. Most urinals have
partitions between them, which may present less of a perceived threat than those
that don’t. Some public urinals (e.g., at some older sports venues) have “trough”-
style urinals, which may present a significant level of perceived threat. Therefore,
you may want to start with urinals that are easier and then gradually make the
exposure more difficult.

• Make flatulence sounds from a stall. As in the in-office exposure, have the client
enter a bathroom stall in a public restroom with others around, sit on the toilet, and
make flatulence noises with his mouth. An “excuse me” can draw even more attention
to the sound.

Safety Behaviors to Eliminate: USING PUBLIC RESTROOMS

Waiting for the public restroom to completely or partially empty out is a common safety
behavior. Instruct the client to do the opposite—try to maximize the “audience” in the
bathroom. Also, some clients with shy bladder will load up on fluids before using the
restroom in order to make sure they urinate. Because the aim here is to practice not uri-
nating, discourage excessive fluid consumption.
130 The Big Book of Exposures

Fear of Social Situations

Many individuals with generalized social anxiety have significant difficulties in
everyday interactions with others. These individuals may avoid making small talk with
others, dating, and being in situations where they might bump into people they know,
such as stores. Ask the client to pay attention to what happens before and during these
social situations and report back to you. For example, perhaps the client went to a party
but didn’t talk to anyone, or drank alcohol before going on a date. This information will
help you tailor future exposures accordingly.

Exposures for Fear of Social Situations

In-Office Exposures: SOCIAL SITUATIONS

• Find a restroom. Ask your client to go to the waiting room area of your office and
ask someone who is walking by or sitting in the office where to find the restroom
(even if your client knows where it is and even if it is obvious where it is located).

• Start a conversation. Have your client initiate conversation with you in session. If
you have others in your office space who can help, it will be useful to have your
client practice with them as well.

• Keep a conversation going. Have your client practice maintaining conversations.

You can reduce your friendliness during an exposure and act withdrawn, giving the
client an increasing level of responsibility for keeping the conversation going.

• Make deliberate blunders. Ask your client to stutter, drop papers, or tremble on
purpose during a conversation with you or with a confederate.

• Play a small-talk game. Play a game with your client (and other colleagues, if
available) in which the client chooses a topic and a time frame to aim for when
talking with others. See rules of the game at the end of this chapter.
Social Anxiety Disorder 131

Out-of-Office Exposures: SOCIAL SITUATIONS

• Connect with new people. Ask your client to consider going on a date with
someone from a dating website or joining a Meetup group in the local area. The
first homework assignment might include just signing up for one of these sites. Later,
encourage the client to chat with people on the website, eventually working up to
going to a group activity or on a brief date (e.g., going for coffee as opposed to
going out for dinner).

• Ask for directions. Have your client ask a stranger where to find the nearest bath-
room or other place. Have him do this several times and record experiences to see
how others tended to react when questioned about where to find a location.

• Attend a party. Ask your client to go to a small party or gathering to which he was
recently invited, and then later go to larger ones (or go alone without friends or
family members if that is something that has been challenging in the past).

• Host a party. Have your client host his own party or small gathering, if this is some-
thing that the client has previously avoided, and invite some people he does not
know well and who could potentially turn down the invitation.

Safety Behaviors to Eliminate: SOCIAL SITUATIONS

Watch out for the following safety behaviors: (1) finding ways to avoid speaking to
authority figures such as bosses, teachers, and police officers, (2) avoiding eye contact
during conversations or interactions with others, and (3) subtle safety behaviors, includ-
ing carrying around a phone or other item in order to look busy and thus avoid social
encounters. Some adolescents with social anxiety use location maps on Snapchat to see
who may be nearby, and then they intentionally avoid those areas. Encourage your
client to refrain from these behaviors. Additionally, your clients might speak with others
but do so in a quiet voice so that it will not be as apparent if they make a mistake.
Therefore, encourage your clients to practice speaking in a louder and more confident
voice.

Many socially anxious clients self-medicate by using benzodiazepines, beta-adrenergic

blockers, alcohol, or other substances prior to social encounters, or drink alcohol in social
situations. Encourage your client to try these exposures without such substances. We
recommend you carefully assess substance use in your clients with social anxiety
disorder.
132 The Big Book of Exposures

Fear of Embarrassment
Since a fear of embarrassment is a core element of social anxiety disorder, it is essen-
tial to target this fear by having your client engage in exposures that lead to (or could
lead to) a feeling of being embarrassed. The goal is not to humiliate your clients during
an exposure, but rather to have them come in contact with the fear to a degree that
would be manageable for someone without social anxiety. We have divided this section
into a fear of embarrassing one’s self and a fear of appearing anxious to others, either by
blushing, sweating, or showing some other sign of outward of anxiety. Note that these
exposures can be combined with the other exposures in this chapter—for example,
giving a speech (performance-related exposure) while appearing sweaty (embarrassment-
related exposure).

Exposures for Fear of Embarrassment

In-Office Exposures: EMBARRASSMENT

• Wear clothes inside out. Have your client walk around the office with an item of
clothing inside out or backward. Consider asking the client to wear two different
shoes or socks to draw more attention from others.

• Ask a silly question. Have your client ask where the nearest bathroom is while
standing in front of the bathroom.

• Toilet paper trail. Ask your client to tape some toilet paper to the bottom of his shoe
and walk around with it.

• Double (or triple) check appointment time. Ask your client to call a doctor’s office
to confirm the time and date of an upcoming appointment at least twice in a short
period of time (e.g., within an hour). At the second call, the client can say something
like “I know you told me, but I forgot; can you repeat the date and time of that
appointment?”

• Walk backward. Ask your client to leave the office and go into the waiting room
while walking backward to draw attention.

• Say hello or goodbye using the wrong name. Introduce your client to a colleague
in your office and then have the client say goodbye using the wrong name. For
example, you can introduce the client to “Cindy” and have it prearranged with your
client to say, “It was nice meeting you, Mindy” at the end of the conversation.
Social Anxiety Disorder 133

Out-of-Office Exposures: EMBARRASSMENT

• Walk backward. Have your client walk backward in the mall, in a store, or on a
sidewalk to draw unwanted attention.

• Pay with change. Either go with your client to a store or ask the client to go alone
and pay for an item with only coins (make sure the client doesn’t count the coins out
ahead of time).

• Eat alone. Ask your client to go to a restaurant and eat alone. Start with easier
places such as fast food chains and then make it more challenging by asking the
client to dine alone in sit-down restaurants.

• Ask a silly question. Ask the client to go into a coffee shop and ask the barista if
coffee is served there.

• Drop an item that makes a loud noise. Have your client drop books on the floor
or coins from a pocket or purse, which will make a loud noise and draw attention.

• Spill a drink. Ask your client to go to a cafeteria, restaurant, or food court and get
a cup of water and then “accidently” spill it on the floor. You can also give your
client a cup of water and ask him to go back out to the waiting room and spill the
drink on the floor in front of others.

• Make a return to a store. Have your client make a purchase in a store and then go
back right away and return it.

• Be wrong. Encourage your client to answer a question incorrectly in class or in a

meeting if it would not be harmful to do so.

• “Forget” money when checking out. Encourage your client to get groceries or
other items in a store and when checking out, tell the cashier the money is in the car
and leave to get it.

• Have a family member draw attention to the client in public. Ask a family
member of the client to help set up an exposure to embarrass the client in public
(with prior permission), such as singing to the client while on an escalator in the mall
where many shoppers are present and can see.

• Wear something goofy. Encourage your client to visit a public place, such as a
shopping mall, while wearing a novelty hat or an attention-getting T-shirt.
134 The Big Book of Exposures

Safety Behaviors to Eliminate: EMBARRASSMENT

Some individuals with social anxiety apologize profusely to others as they do not want
to offend anyone. Many times these apologies will be for very minor things that do not
require an apology. One goal will be to eliminate excessive apologies to others.
Additionally, often clients with social anxiety will make qualifying statements to others
about why they are returning things to stores, why they dropped an item, or why they
were wrong about something, in order to try to lessen their anxiety. For example, a client
might make a return to the store but make an elaborate excuse about why he is returning
it rather than just returning it. Ask clients to do these exposures without the qualifying
statements.

Watch for avoidance of making eye contact with others and help the client start making
eye contact again by practicing with you and then with others.

Clients might be doing the exposures that you asked them to, but during times when
stores or other areas are less crowded so that there is a lower chance of being embar-
rassed or having others see them. Watch out for this and ask your clients if they tend to
let anxiety dictate when they do the exposures rather than doing them at a time that
maximizes the exposure.

Some fearful clients take medications, such as benzodiazepines or beta-adrenergic

blockers, or use alcohol prior to giving a speech or being the center of attention where
they might feel embarrassed. Encourage your client to try these exposures without such
substances, choosing instead to feel the fear and allow it to come back down on its own.
Social Anxiety Disorder 135

Exposures for Fear of Appearing Anxious

In-Office Exposures: APPEARING ANXIOUS

• Get sweaty. Have your client put water on his forehead, under his arms, or on other
areas of clothing (e.g., back of shirt, collar) to mimic looking sweaty and then walk
around the office space or the parking lot so that others may see that the client is
“anxious.” Make this exposure more anxiety provoking by pairing it with giving a
speech or having a conversation with someone so that the sweaty look is more likely
to be noticed.

• Stutter. Ask your client to stutter on purpose while speaking with someone else.

• Look shaky. Ask your client to appear shaky to others by moving his hands and
jiggling his legs so that others could potentially see that he is nervous. Even if this is
a symptom that happens naturally for the client, ask him to make it more exagger-
ated to really come into contact with this fear and make it apparent to others.

• Wear makeup to look anxious. Have your client put blush on his cheeks to look
flushed and anxious.

• Use a confederate. Have a confederate point out to the client how nervous he
appears by saying something such as “Wow, you are really sweating! Are you
okay?” or “I’ve never seen you look so shaky before.”

Out-of-Office Exposures: APPEARING ANXIOUS

• Do the in-office exposures listed above in public places. Have your client go to
work, school, or other public places (e.g., running errands, going to the grocery
store) while using the above ideas to target fear of looking anxious (e.g., being
shaky on purpose, wearing blush, looking sweaty on purpose).
136 The Big Book of Exposures

Safety Behaviors to Eliminate: APPEARING ANXIOUS

Some clients will have a prescription for a beta-adrenergic blocker so that they will not
experience physiological signs of anxiety. Encourage the client to practice doing expo-
sures without having taken the medication beforehand. Additionally, make sure your
client isn’t using alcohol or drugs to help get through an exposure or make exposures
easier.

Ask the client to refrain from apologizing during exposures related to embarrassment,
which provides him with temporary relief but is not helpful in the long run. Also, If the
client is naturally experiencing blushing, sweating, shaking, or other symptoms, encour-
age him to continue with what he was doing, such as sitting in a meeting or going to the
store, rather than avoiding it or coming up with an excuse to leave early. Finally, clients
might have the tendency to try to rush through the exposure; encourage them to slow it
down and really stick with it in full, rather than quickly trying to finish it.

CONCLUSIONS
The fear in social anxiety disorder is twofold. First, clients who are socially anxious fear
specific social and performance situations, such as public speaking, being watched, using
public restrooms, and initiating or maintaining conversations. In this chapter, we’ve pro-
vided several ideas for in vivo and imaginal exposure that will help your client confront
these feared situations. Second, people with social anxiety disorder are often afraid that
they will exhibit outward signs of anxiety, or will make blunders, that will prove embar-
rassing. Here, we recommend that you address these concerns directly by encouraging
the client to tolerate embarrassment by deliberately making errors or mimicking signs of
anxiety such as sweating, shaking, blushing, or stuttering. These exercises aim to help the
client recognize that even embarrassing social encounters need not be catastrophic.
In the next chapter, we will provide detailed exposures for your clients who have
been diagnosed with obsessive compulsive disorder (OCD).
Social Anxiety Disorder 137

CHAPTER RESOURCES
Reminder: These resources are also available to download and print from http://www
.newharbinger.com/43737.

Example Imaginal Exposure Script—Performance-Related Fears

I get up out of my seat and walk to the front of the room to give my presentation to
the audience. The room is quite full, and I feel hot and sticky. My heart feels as
though it will pound out of my chest and I begin to feel the sweat pooling under my
arms. I attempt to pull up my presentation slides on the big screen, but there is a glitch
and I can’t get it to work. All eyes are on me and I begin feeling more and more
nervous. The room is silent and I try to break the silence by saying, “We are having
technical difficulties,” but no one offers to help me. They just keep staring at me.
I scramble trying to fix my slides as soon as possible. Eventually it is fixed and I can
begin, though I am already so worked up from my slides not working that I feel close
to panic. I stutter over my words as I begin to speak and notice the audience silently
judging me. I try to hold the audience’s attention, but I see them becoming bored.
Some are looking at their phones while others are making quiet comments to each
other. I try to focus on my presentation, but all I can think about is what they all are
thinking about me. All of a sudden, the audience members start leaving the room.
I try to hold it together but I feel a rush of blood go to my face and I know I must be
bright red. I want to run out of the room, but my presentation and career will be
ruined.
138 The Big Book of Exposures

Small-Talk Game
Materials:
• Small pieces of paper/index cards/sticky notes
• Writing utensils
• Timer on phone or watch

Write down a list of different topic ideas on small pieces of paper. Examples include
weather, sports, TV shows/movies, hobbies, and books. Put all ideas in one pile. In
another pile, put lengths of time on separate pieces of paper. Examples include thirty
seconds, one minute, two minutes, and so on. You can use and cut up the table provided
below or create your own.

Ask your client to choose (without peeking) one card from the topic pile as well as one
from the time pile. Set the timer for the length of time chosen and begin the exposure
with the topic chosen by the client. You can start by having the client engage in small talk
with one or two people and then later ask your client to stand up and give a presenta-
tion on the topic that was chosen. Add more complicated topics and longer time frames
for more challenging exposures!

30 seconds Hobbies
1 minute Current movies and TV shows
2 minutes Vacations (e.g., favorite spot or place on
bucket list)
3 minutes School/work
5 minutes Current affairs
7 minutes Controversial topics (e.g., death penalty,
abortion)
 CHAPTER 8

Obsessive-Compulsive Disorder

In this chapter, we will give a brief overview of obsessive compulsive disorder (OCD) and
provide detailed exposures to help your client who has OCD face her fears of contamina-
tion, forbidden or taboo thoughts, fear of causing harm (to self or others), a need for
symmetry, and much more.

WHAT IS OBSESSIVE-COMPULSIVE DISORDER?

OCD is present in approximately 2% of adults (Kessler et al., 2012). According to the
DSM-5 (APA, 2013), the criteria for OCD are:

A. The presence of clinically interfering and distressing obsessions, compulsions, or

both.
Obsessions are defined as:
1. Recurrent, persistent, intrusive thoughts that cause marked anxiety or
distress.
2. The person attempts to ignore or suppress the thoughts or neutralize them
with compulsive behaviors.
Compulsions are defined as:
1. Repetitive behaviors or mental acts that the person feels compelled to
perform in response to obsessions or according to rigidly applied rules.
2. The behaviors or mental acts are done as an attempt to alleviate the obses-
sions, to feel less anxious, or to prevent a feared consequence from
occurring.

B. The symptoms are time-consuming (e.g., one hour or more per day) or cause
significant distress or functional impairment in social, occupational, or other
areas of functioning.

C. The symptoms must not be attributable to the physiological effects of a

substance, medication, or medical condition.
140 The Big Book of Exposures

D. The disturbance must not be better explained by another mental health

disorder (e.g., thought insertion or delusional preoccupations as seen in
psychotic disorders).

Obsessions come in many different forms, including worries about touching dirty
items, harming oneself or others accidentally or by uncontrollable impulse, having
uncomfortable thoughts about religion or sex, or making mistakes.
Compulsions can be visible, such as when someone repeatedly washes her hands or
repeatedly seeks reassurance from a loved one. Other times, compulsions can be subtle
and not observable to others. Examples of subtle compulsions may include mentally
praying, counting, or reassuring oneself that things are okay.

Fear and Avoidance in Obsessive-Compulsive Disorder

In most cases, individuals with OCD fear some dreaded consequence if they do not
perform a compulsive behavior (see Foa, Kozak, et al., 1995). Individuals with contami-
nation-related obsessions often fear contracting a disease if they touch something that
seems “dirty.” Individuals with harm-based obsessions may fear that they will injure or
kill someone, either accidentally (e.g., by hitting them with a car or leaving the oven on)
or in response to an uncontrollable impulse (e.g., that they will be seized with the urge to
grab a knife and stab someone).
Sometimes, the feared stimulus in OCD is internal to the person. In particular, many
clients experience “forbidden” thoughts—for example, the thought I hate God or I want
to molest children may intrude into consciousness. In such cases, the person may fear that
she will be punished for these thoughts, or that the thoughts signify that she is danger-
ous, immoral, or crazy.
In some cases, the person with OCD is unable to identify a feared consequence
other than prolonged distress. An individual with symmetry-based obsessions, for
example, might fear that leaving things uneven will cause a disaster to occur; however, in
other cases, the feared consequence may simply be “I will become so upset that I won’t
be able to stand it and will feel distressed forever.”
Avoidance in OCD can be either passive or active. Passive avoidance strategies refer
to what the person does not do—for example, the client with contamination fears may
refrain from touching anything that appears “dirty.” Active avoidance strategies are the
compulsions (safety behaviors) in which the person actively tries to “neutralize” fears or
obsessive thoughts through an action of some kind—for example, if the client with con-
tamination fears accidentally touches something “dirty,” she may feel a need to wash her
hands repeatedly. Passive and active avoidance strategies both serve to maintain fear (see
chapter 1).
Obsessive-Compulsive Disorder  141

Avoidance can also be either physical or mental. Physical avoidance is the avoidance
of stimuli external to the person; for example, an individual with harm-related obsessions
might avoid being around knives in order to maintain a sense of safety. Mental avoidance
refers to efforts to avoid thinking obsessive thoughts. For example, when the person with
harm-related obsessions has a thought about hurting others, she might try to distract
herself, engage in mental rituals, or otherwise attempt to suppress the thought—which
often has a paradoxical effect, resulting in thinking about it even more (Tolin,
Abramowitz, Przeworski, & Foa, 2002; Wegner, Schneider, Carter, & White, 1987).

Important Considerations in the Assessment and

Treatment of Obsessive-Compulsive Disorder
It’s important to assess the client carefully, particularly in cases of harm-related
OCD. Some clients are truly suicidal or homicidal, for example, whereas others are
plagued with obsessive thoughts about harm to themselves or others. You can make the
distinction by examining the extent to which the thoughts are perceived as intrusive or
unwanted, and the extent to which they cause emotional distress. Suicidal individuals,
for example, deliberately think of harming themselves and often gain a sense of emo-
tional comfort from the thoughts. Individuals with self-harm obsessions, on the other
hand, find the thoughts distressing when they arise, and they experience the thoughts as
unwanted. Understanding the client’s history (e.g., the extent to which they have engaged
in harmful behaviors in the past) is another important factor to consider prior to expo-
sure therapy.
Another important consideration in the assessment and treatment of OCD is the
onset of a child or adolescent’s symptoms. Check in with the parent(s) to see if the child
had a sudden and intense onset of symptoms. If so, you should consider the possibility of
pediatric autoimmune neuropsychiatric disorder associated with streptococcus, other-
wise known as PANDAS (Leonard & Swedo, 2001). This can occur following an infec-
tion, such as strep throat. Be aware that other infections can cause similar symptoms,
such as Lyme disease, which is attributed to pediatric autoimmune neuropsychiatric syn-
drome (PANS; Swedo, Leckman, & Rose, 2012). While exposure will still be the treat-
ment of choice for obsessive-compulsive symptoms caused by PANDAS or PANS, it will
be important for the child to have bloodwork and/or a throat culture to see if medical
interventions are also needed. Therefore, if you suspect these sudden onset symptoms are
the result of PANDAS or PANS, refer your client to her primary care provider for further
testing and evaluation.
142 The Big Book of Exposures

BEHAVIORAL TREATMENT FOR

OBSESSIVE-COMPULSIVE DISORDER
In this chapter, we have divided the in-office and out-of-office exposure ideas for OCD
into commonly seen categories of the disorder:
1. Contamination-related fears
2. Scrupulosity-related fears
3. Pedophilia-related fears
4. Harm-based fears (of self and others)
5. Ordering/arranging/“not just right”/symmetry
6. Checking

Contamination-Related OCD
Contamination-related OCD is one of the most common types of the disorder. This
category includes a fear of developing an illness. The fear can be vague, such as thinking,
I will get sick, or it can involve more specific obsessions of getting an illness, such as I will
contract HIV. Below is a list of exposures that are aimed to target this fear.
Obsessive-Compulsive Disorder  143

Exposures for Contamination-Related Fears

In-Office Exposures: CONTAMINATION

• The Contamination Macarena. Whenever you ask clients to touch a contaminated

object, you want to make sure they fully engage with the perceived threat by getting
the “germs” all over them. OCD, like many other anxiety-related disorders, is famous
for “yes-but”-ing the exposures: “Yes, I touched that dirty object, but I survived
because the germs are only on the tip of my index finger.” So, it’s important to
spread the contamination around. Have your client touch the feared object with his
or her entire hand, then rub his or her hands together, and then use both hands to
touch his or her clothing, hair, and face, as if dancing the Macarena.

• Create an imaginal exposure script. Ask your client to write a detailed exposure
script about getting contaminated and becoming extremely ill or dying.

• Eat foods that others have touched. Keep a box of crackers, candy, or other small
snacks in your office and have the client reach for it and eat from it while reminding
her how many people have also eaten from that box and how germy it could be.
You can also ask the client to think about what sorts of diseases she may catch from
the box of food (e.g., conjunctivitis, stomach bug).

• Flossing. Floss your teeth and then hand the floss to your client to touch or hold so
that she can come into direct contact with, and “catch,” your germs. You can begin
by having the client touch part of the floss that wasn’t in your mouth (such as the end
of the floss) and then later touch all parts of the floss that were “contaminated.”

• Eat fruits or vegetables. Have your client eat fruits or vegetables without washing
them first. Talk to your client about how many people might have touched those
foods in the grocery store. Discuss the fact that pesticides may be covering the fruit
and that these pesticides are now entering the client’s body.

• Shake hands. Bring your client around the office and introduce her to people, with
the aim of shaking hands with others. This targets the client’s fear of becoming con-
taminated, as well as a fear of accidentally contaminating or harming others. For
clients with a fear of contaminating others, “contaminate” the client’s hands prior to
the exposure by having her touch things that she considers to be dirty or dangerous,
such as cleaning supplies.

• Germ spreading. Have a “sneezing contest” (without covering the sneeze with your
hand) in the office with your client and any others (e.g., colleagues, family members
of client). Give awards to the person with the most realistic sneeze and the person
who has the sneeze that travels the farthest.
144 The Big Book of Exposures

• More germ spreading. Have the client touch a “contaminated” object and then
prepare food for others without washing her hands, as long as it is reasonably safe
to do so.

• Eat food off of the floor. Drop a snack onto the floor for your client and then have
her eat it. Begin by using food items that may not collect as many germs or dirt on
them, such as a cracker, but then later drop more challenging items such as a piece
of cheese or some peanut butter, which is more likely to have stuff on it after being
on the ground. Have the client brush off any visible dirt, then eat the snack.

• Touch doorknobs. Walk around the office space with your client and have her
touch all doorknobs in the building (make sure the palm of the hand comes into
contact with the door). This exposure, like all touching-related contamination expo-
sures, can be intensified using “The Contamination Macarena” described above.

• Sit on the bathroom floor. Sit on the bathroom floor with your client and go back
and forth talking about all the types of germs that may now be on your pants and
other parts of your body.

• Sit on a public bathroom seat. Ask your client to use the bathroom in your office
or another public space without putting down toilet paper first.

• Touch items in a public bathroom. Have your client flush the toilet with her hands,
as opposed to using a foot or toilet paper. You can then instruct your client to touch
the toilet seat and then touch her clothes, or face, or hair.

• Trash touching. Have the client touch outside parts of a trash can without gloves or
other protective material. To later make the exposure more challenging, you can
have the client reach into a trash can and touch items inside or rub her hands on the
trash can lining.

• Touch bodily fluids. Have the client use toilet paper to collect a microscopic sample
of urine, feces, semen, or other “dirty” bodily fluids, then practice touching the
paper and spreading the contamination.

• Eat in the bathroom. Eat while sitting on the bathroom floor, using the toilet seat as
a table.

• Play games with contaminants. Especially (though not exclusively) for young
people with OCD, it can be useful to adapt games to incorporate contaminants. For
example, you could play a game of catch using a raw meatball, play checkers using
dead cockroaches, or have a squirt gun fight in which the water has been “contami-
nated” with a drop of urine or blood.
Obsessive-Compulsive Disorder  145

Out-of-Office Exposures: CONTAMINATION

• Get dirty. Encourage the client to cover her hands with dirt from outside and to get
the dirt in between the fingers and under the fingernails.

• Go on a scavenger hunt. Have your client go on a hunt to pick up trash in the

neighborhood or office complex to do a good deed! Tell you client to consider
having a snack afterward (without washing her hands).

• Dumpsters. Have the client go outside your office building or to other buildings to
touch dumpsters (hospital dumpsters may be rated as even higher-level exposures by
clients). She can start by standing near the dumpster, touching the outside of the dump-
ster, touching the inside of the lid, and then putting her hand inside of the dumpster.

• Use public transportation. Ask the client to hold onto the pole in a subway without
wearing gloves or other protective gear.

• Be with others who could be sick. Have your client sit in a waiting room at a physi-
cian’s office or hospital, where many sick individuals will be walking in and out.
Depending on how busy the waiting room is, you can have the client think about or
talk with you about the various illnesses that could be floating around the hospital
or doctor’s office that have now “contaminated” the client.

• Bottle up contaminants. Ask the client to put “contaminants” into a spray bottle
and carry the bottle around with her, spreading the contaminants. For example, the
client could have a family member cough or sneeze into the bottle first and then
spray “clean” things (e.g., interior of car, keyboard of laptop, cell phone) to con-
taminate them.

• Make or buy a contamination object. Have the client make (using online tutorials)
or buy slime, putty, or playdough and then contaminate it by bringing it into the
bathroom and touching the floor or toilet with it. The client should carry the slime,
putty, or playdough around and/or play with it throughout the day and week.

• Wear a contamination necklace. Ask your client to contaminate an item that she
can wear on a necklace or lanyard around the neck; this way the contaminated
object will be close to the face and therefore may be perceived as more likely to
get her sick. The client can contaminate items by bringing them into the bathroom,
rubbing them on the floor, having others touch them, or putting them in the dirt.

• Be in close proximity to chemicals. Encourage your client to keep an open bottle

of a “toxic” chemical around, such as on the bedside table or near food.

• Eliminate “clean” zones. Many individuals with contamination-related OCD have

“clean” and “dirty” zones in their homes. The “clean” zones are areas from which the
client has prevented the entry of contaminants. Encourage the client to wear con-
taminated clothes or bring other items that are considered “dirty” into the clean
zones of the home, thus eliminating the “clean” zones altogether.
146 The Big Book of Exposures

Safety Behaviors to Eliminate: CONTAMINATION-RELATED FEARS

Many clients will wear protective gear such as gloves or use the sleeve of a shirt when
touching “contaminated” objects, but this will greatly interfere with the learning process,
so encourage them to remove these protective barriers. Also, check in with the client to
make sure that she does not have friends or family members participating in compulsions
(e.g., opening doors so that the client does not have to touch them).

Clients will have an urge to wash or use hand sanitizer after touching “contaminated”
objects. However, this behavior will serve to “undo” the exposure, especially if the client
is only getting through the exposure by knowing that she can wash later. Gently remind
the client that we wouldn’t want to undo all of the hard work she just did in session or for
homework. This can help motivate her to stick with the uncomfortable feelings without
engaging in compulsive behavior. Check in with your client to make sure that she client
does not take excessively long showers, or shower frequently throughout the day, as a
way to alleviate anxiety; help the client reduce the amount of time in the shower each
day until the client is completely abstaining from this safety behavior, meaning that she
might not be showering for days.

Some clients may touch or sit in public spaces but then make sure that they don’t touch
certain areas of their home or car in an effort to prevent contamination and to keep
certain places “clean.” Clients with contamination-related OCD often have “clean zones”
and “dirty zones.” They often keep the “clean zones” pristine from outside contamina-
tion. For example, some clients will have certain clothes that they believe are okay to be
worn in the house as they are deemed “clean,” while other clothes are allowed to be
worn out of the house but then cannot be worn in the home for fear of contaminating the
“clean” rooms of the home. Make sure to check in with your client about this and remove
these behaviors as soon as possible as they only serve to maintain the anxiety in the long
term. Encourage the client to spread contamination to the “clean zones.” Remember,
“clean” is the enemy!

Scrupulosity-Related OCD
Another common type of OCD includes scrupulosity-related fears of not being moral
enough, offending a religious figure or religion, or having preoccupations about sex, sexu-
ality, or violence. We begin this section of exposures by tackling the fear of offending a
religious figure or of not acting morally enough. This can be a tricky type of OCD, as you
need to be sensitive to the client’s religious beliefs. It is helpful to have a conversation
with your client about her religious beliefs without OCD being part of the picture. This
will help you discern what is a religious belief and what is an OCD thought or behavior,
which you can then challenge. The goal is never to get a client to change her religious
beliefs. If needed, you can ask for permission to contact the client’s minister, rabbi, or
priest for additional guidance or assistance.
Obsessive-Compulsive Disorder  147

Exposures for Scrupulosity-Related Fears

In-Office Exposures: SCRUPULOSITY-RELATED FEARS (RELIGION)

• Draw pictures. Have your client draw a picture of the devil (or other feared being)
or print a picture of the devil from the Internet and color it in, while repeatedly
stating the feared outcome, such as “I could go to hell for drawing this.”
• Imaginal exposure. Create an imaginal exposure script to target the client’s worst
fear, such as doing something to upset God or a religious figure and the conse-
quences of it (e.g., dying, going to hell, or being punished in other ways).
• Make a spirit board (popularly known as a Ouija board). With the client, create
a spirit board out of cardboard and printed letters to be glued onto the board (see
“Chapter Resources” at the end of this chapter for a description, instructions, and a
template).
• Say feared statements aloud. Depending on the client’s fears, have the client make
statements repeatedly such as “I hate God,” “I am sinful,” or “I will burn in hell.”
• Use Pig Latin. Have the client say prayers or other ritualistic phrases in “Pig Latin”
in order to break up the ritual and potentially offend the higher power. For example,
if the client repeatedly says, “God, please keep me safe,” this would be translated
to “Odgay, easeplay eepkay emay afesay.”
• Rip up a book. Get a religious book or hymnal and have the client tear pages out
of it.
• Read the Bible in the bathroom. Bring the Bible or other religious text into a bath-
room so that it becomes “contaminated” and could offend God or a religious figure.
• Fake tattoos. Draw “666” in black marker on the client’s arm and have her wear it
around all day. To make it even more challenging, have the client enter a place of
worship with that on underneath her clothes.
• Pray to the devil. With the client, light a candle and ask for the devil to take your
souls. You can use this popular Satanic prayer:

Our Father, who art in hell

Cursed be thy name
Thy kingdom upon earth has come
Thy will be done in hell as it is on earth
Grant us your power and might
And lead us into temptation
Deliver us unto evil
Thine is the kingdom of earth
The power and the glory
Forever and ever
So it is done.
148 The Big Book of Exposures

Out-of-Office Exposures: SCRUPULOSITY-RELATED FEARS (RELIGION)

• Carry “bad” pictures. Have your client secretly carry pictures of the devil, a well-
known murderer, or other “bad” beings or people into a religious building.

• Think “bad” thoughts. Have the client think “bad” thoughts (e.g., curse words,
sexual content) while in a church or other religious building.

• Buy a devil figurine. Ask your client to place an order online for a devil figurine
and then leave it in her bedroom or on her desk at work. You can later make this
exposure more challenging by having the client pray to the devil figurine and say
aloud that she follows this devil figurine.

• Try to contact spirits. Ask the client to purchase a Ouija board or bring a spirit
board that she made in session into her home.

• Take communion “incorrectly.” Have the client drop a piece of the communion
wafer or take it a little bit earlier or later than is normally done in the specific place
of worship where the client attends.

• Have nonkosher food nearby. If the client is keeping kosher, you can ask her to
have nonkosher food in the vicinity of the other food that she will eat, without actu-
ally eating the nonkosher food.

Safety Behaviors to Eliminate: SCRUPULOSITY-RELATED FEARS

Make sure that the client isn’t praying excessively or saying any prayers that serve to
“undo” exposures. Also, some clients will want to seek reassurance from God or another
religious figure following an exposure; encourage the client to resist this urge. Finally,
work to eliminate any safety behaviors that consist of excessively confessing, either to
friends or family or to a priest, rabbi, or minister.
Obsessive-Compulsive Disorder  149

Pedophilia-Themed OCD
Some clients with OCD have frightening thoughts that they are (or will become) a
pedophile or will engage in sexual acts with children. How is this different from pedo-
philia, and how can you tell the difference between the two? There are several features
that differentiate the two disorders, as shown in table 3.

TABLE 3. Differences between

pedophilia-themed OCD and pedophilia

Pedophilia-Themed OCD Pedophilia

Frequency and Very frequent, intrusive, Less frequent, voluntary,
intensity of thoughts and distressing and gratifying
Content of thoughts Fear of sexual attraction Sexual attraction to children
to children
Behavioral response No action on thoughts Action on, or masturbation
to thoughts toward, thoughts
Avoids triggers, minimizes
contact with children Seeks out children or
child-related stimuli,
engages in grooming
behavior
Cognitive response Thought suppression Fantasizing
to thoughts
Presence of other Common Less common
OCD symptoms

As shown in the table 3, individuals with pedophilia-themed OCD experience

sexual thoughts about children as being frequent, intrusive, and distressing. They are
characterized by a fear of being sexually attracted to children, rather than an actual
sexual attraction toward children (see Bruce, Ching, & Williams, 2018; Veale, Freeston,
Krebs, Heyman, & Salkovskis, 2009; Vella-Zarb, Cohen, McCabe, & Rowa, 2017). The
anxiety will rise every time they experience a thought such as What if I looked at that child
inappropriately? or Did I just feel aroused when seeing that picture of my child’s friend? The
individual with OCD begins to question herself and has fears that she is a monster and a
terrible person. These intrusive thoughts torment the individual, who may then engage
in compulsive behaviors or avoidance behaviors. She may avoid or attempt to avoid chil-
dren (maybe even her own), or engage in neutralizing behaviors. For example, an indi-
vidual with these intrusive thoughts may take the long way home from work to avoid
150 The Big Book of Exposures

driving by a playground filled with children. Or a father may no longer change his child’s
diaper and instead ask his spouse to do it. This is in stark contrast to pedophilic disorder,
described in the DSM-5 as recurrent, intense sexual fantasies, urges, or behaviors involv-
ing sexual activity with a prepubescent child for a period of at least six months and acting
upon these urges (APA, 2013). Individuals with this disorder are attracted to young
children and will seek out opportunities to prey on children or come into contact with
them, such as going to playgrounds, looking at child pornography, or molesting a child.
Once we have determined that our client has OCD and not pedophilia, we do not fear
using exposure strategies.

Exposures for Pedophilia-Themed Fears

In-Office Exposures: FEARS OF BEING/BECOMING A PEDOPHILE

• Repeating scary phrases. Ask your client to repeatedly state, “I am a pedophile”

or “I am attracted to children.”

• Read stories of sexual abuse by clergy. Read stories of clergy who engaged in
molestation of young children with or to your client. To make the exposure more
challenging, you can ask your client to say, “If religious figures could do this, then I
am capable of it too.”

• Watch video clips of pedophiles. Conduct an online search for people who have
been arrested for pedophilia who talk about their stories. While watching these
clips, have your client repeatedly state, “This could be me” or “I am just like this
person.”

• Agree with pedophiles. Watch clips of known pedophiles who talk about how
sinister or sneaky they were to approach children or get them to comply and have
your client say, “That was a good idea.”

• Look at swimsuit advertisements. Conduct an online search with your client for
children’s swimsuit ads and have your client look closely at the pictures without
averting her gaze.

• Rate attractiveness. Look up online photos of children and ask your client to rate
the sexual attractiveness of the children.

• Write an imaginal exposure script. Work with your client to create a detailed
imaginal exposure script related to her fears of being attracted to a child, engag-
ing in inappropriate acts, and ultimately being arrested for child molestation.
Obsessive-Compulsive Disorder  151

Out-of-Office Exposures: FEARS OF BEING/BECOMING A PEDOPHILE

• Go to previously avoided places. Ask your client to visit places once avoided, such
as to go to a playground with her children again or to drive past schools.

• Read an imaginal exposure script. Ask your client to bring her imaginal exposure
script to a place where there are children and read it silently or listen to it through
headphones while looking at children.

• Watch a documentary. Ask your client to watch documentaries with the theme of
pedophilia, such as Leaving Neverland, The Paedophile Next Door, or Abducted in
Plain Sight. Your client can make the exposure more challenging by stating feared
phrases (e.g., “I am a pedophile,” “I am attracted to children”) while watching the
show.

Safety Behaviors to Eliminate: PEDOPHILIA-THEMED FEARS

Make sure that the client isn’t saying things that serve to “undo” the exposure, such as
going through all the reasons why she is not a pedophile. In addition, some clients will
want to seek reassurance from others or from the Internet that they are not a pedophile.
Your client may be conducting online searches for the differences between OCD and
pedophilia on a frequent basis. Work with your client to reduce these reassurance-
seeking behaviors.

Work to eliminate any safety behaviors that consist of your client’s avoiding normal,
everyday activities such as changing her child’s diaper, helping the child in the bath-
room, or helping the child get dressed for school, which the spouse might have taken
over to help alleviate the client’s anxiety.
152 The Big Book of Exposures

Harm-Based OCD
Harm-based OCD thoughts can be a fear of harming oneself or others (e.g., signifi-
cant other, children, random person). The client, of course, does not have a desire to
harm herself or others and is highly concerned that it could happen because she is not
careful enough. She may also fear that she could randomly act impulsively to harm
someone even with no history of this in the past. Naturally, it is crucial that you have
diagnosed your client carefully and that it is clear that the client has OCD rather than
actual suicidal or homicidal ideation. Table 4 shows some key differences between harm-
related OCD and actual suicidal or homicidal ideation. As we saw in the example of
pedophilia-themed OCD above, the critical distinction is that individuals with OCD fear
harming themselves or others, whereas people with suicidal or homicidal ideation desire
or fantasize about harming themselves or others. Of course, it’s worth noting that people
with OCD can frequently have true suicidal ideation; therefore, careful assessment is
critical. We wouldn’t want to do suicide-related exposures with a truly suicidal individ-
ual; on the other hand, we don’t want to treat harm-related OCD thoughts without
exposure.

TABLE 4. Differences between harm-related

OCD and suicidal or homicidal ideation

Harm-Related OCD Suicidal or Homicidal

Ideation
Frequency and Very frequent, intrusive, Less frequent, voluntary,
intensity of thoughts and distressing dependent on negative
emotion, can be comforting
Content of thoughts Fear of harming self Desire to harm self or others
or others
Behavioral response No action on thoughts Planning harm to self or
to thoughts others, or actual harming
Avoids triggers, such
behaviors
as sharp objects
Cognitive response Thought suppression Wishing or fantasizing
to thoughts
Presence of other Common Less common
OCD symptoms
Obsessive-Compulsive Disorder  153

Exposures for Harm-Based Fears—Self

In-Office Exposures: FEAR OF HARMING SELF

• Be around knives. Sit in the office with your client with a knife block on the table.
Ask your client to stare at the knives and repeatedly say, “I could grab those knives
and stab myself.”

• Watch video clips. Watch video clips with your client of television shows or movies
online that portray people engaging in self-harm and/or talking about it, such as
the movies Girl, Interrupted and Thirteen.

• Use imaginal exposure. Write a detailed and gory story with your client about
harming oneself and the consequences of that behavior, such as a trip to the emer-
gency room, being locked up in a psychiatric ward, or even death (see the sample
imaginal exposure script at the end of the chapter).

• Hold knives. Have your client hold a knife block and then start holding different
knives within the knife block, starting with a butter knife and working up to a butcher
knife. Later you can ask your client to hold a knife while stating, “I’m going to stab/
cut/kill myself.” The client can (carefully) hold the knife to her wrist to intensify the
exposure.

• Be around a bottle of pills. Have your client look at or hold a bottle of pills. Ask
the client to repeatedly say, “I’m going to take these and overdose.”

• Confront heights. With your client, stand by an open window on a high floor or find
some other high place to go (see chapter 5 for some examples). Have the client look
down and repeat, “I’m going to jump.”
154 The Big Book of Exposures

Out-of-Office Exposures: FEAR OF HARMING SELF

• Watch videos while home alone. Have your client watch movie clips of individuals
who harmed themselves.

• Be around sharp objects. Tell the client to have a pair of scissors or a razor lying
on the table next to her.

• Go to a kitchen store. Have your client visit the knife aisle of a kitchen store or
other large store that may have various knives (e.g., butcher knife, bread knife) to
see and/or touch. The client may need to begin the exposure with someone else
accompanying her and then later should spend time in the aisle alone.

• Cook with knives. Ask your client to prepare a meal using various sizes of knives.
At first, the client may need to do this while others are home, but then she can
advance to cooking with knives while home alone.
Obsessive-Compulsive Disorder  155

Exposures for Harm-Based Fears—Others

In-Office Exposures: FEAR OF HARMING OTHERS

• Use imaginal exposure. Write a detailed story with your client about harming
someone while either driving or being around sharp objects. Make sure to encour-
age her to add all the gory details as well as the consequences of the harming
behavior, such as going to jail. (See the sample imaginal exposure script at the end
of this chapter.)

• Be around knives or other sharp objects. Sit with your client in the office with a
knife block or scissors on the table. Then ask colleagues or friends and family
members to join the session so that the client can be around sharp objects and
people at the same time.

• Hold sharp objects. Have your client hold knives from a knife block or other items,
such as scissors. You can later ask your colleagues or friends and family members of
the client to be present in the session without having the client touch the others at this
point. The client can also say, “I am going to hurt one of you” while holding the sharp
object but not make any motion, at this point, toward the others in the room.

• Say threatening words. Have the client point any knife (depending on how high up
on the hierarchy) at you and repeatedly state, “I’m going to hurt/kill/cut you.”

• Hold sharp objects to others. Have the client hold a butter knife to your wrist.
Increase the intensity of the exposure by later having the client hold more challeng-
ing knives such as steak knives or butcher knives to your wrist. You can then create a
more challenging exposure in which you ask your client to hold a butter knife (and
then later sharper knives, such as a butcher knife) to your neck, maybe starting with
touching the side of the neck with the knife and then moving to the front of the neck.

• Kill people with thoughts. Stand at the window of your office with your client and
have your client try to “kill” people with thoughts. This may be even more challeng-
ing with children or elderly people. You can have the client think, I hope you die or I
want you to die as the person walks by. Have the client try to appear mean and
menacing, rather than looking scared or anxious, while thinking these thoughts. You
can also have the client practice saying this about loved ones such as by saying, “I
want         to die in a car accident.”

• “Poison” someone. Have your client stand near chemicals, such as cleaning sup-
plies, in your office and then go into the hallway and have the client offer candy to
someone directly from her hand. This will help target the fear that the client could
have somehow put chemicals into the candy and contaminated another person.
156 The Big Book of Exposures

Out-of-Office Exposures: FEAR OF HARMING OTHERS

• Cook with knives. Ask your client to prepare meals at home using large knives
while other people are around.

• Carry knives around. Have your client carry knives in public. If needed, the client
can start with plastic knives and work up to a sharp pocketknife.

• Sleep with knives in the bedroom. Ask the client to sleep with a large knife in the
nightstand or near the bed to target the concern that she may grab it impulsively in
the night and harm someone.

• Take a drive. Have your client drive while someone in the car says, “You are going
to hit someone.”

• Run over an object. Ask the client to drive over a life-size dummy (you can make
one out of a long-sleeved shirt and pants, stuffed with foam rubber or similar mate-
rial) to practice hitting someone. Note that you should do this exposure in a more
secluded area to avoid having passersby think someone is actually being run over.

• Use baby dolls. Have your client drive slowly around a parking lot while you toss
baby dolls at the car so that the client hears the thump of the “baby” hitting the car
and sees the “baby” flying off the hood or back of the car. You can also have the
client put a doll on the ground and run over it repeatedly with the car.

• Drive during peak hours. Have your client drive during rush hour or in busy parking
lots. You can also ask others to join the session and stand in various places in the
parking lot and slap the car as the client drives by.

• Carry potentially harmful items. Have your client carry silicone packets (that
often come in shoe boxes or with other items you have purchased) and go to a
buffet or salad bar to potentially come into contact with someone else’s food while
carrying “poison.”
Obsessive-Compulsive Disorder  157

Safety Behaviors to Eliminate: HARM-BASED FEARS (SELF AND OTHERS)

Some clients will have removed all of the knives or sharp objects from the home, so make
sure the client is bringing those everyday items back into the home. If the client is having
others chop vegetables or use utensils or other sharp items for her, work on having the
client do these things again.

To make sure that they did not accidently hit someone with their car, some clients will
seek reassurance from friends or family, check the rearview mirror of the car repeatedly
to make sure no one is lying on the road, turn the car around to make sure no one was
hurt, or check the news to ensure there were no hit-and-run accidents that day that they
might have been involved in. Encourage the client to stop these behaviors. Some clients
who fear hit-and-run accidents will not drive with music on so that they can hear more
clearly if they hit someone. Therefore, ask the client to start playing soft music while
driving and work up to having loud music playing while driving. Also encourage clients
to refrain from having friends or family members drive them as a way to avoid facing
the fear of driving.
158 The Big Book of Exposures

Ordering/Arranging/“Not Just Right”/Symmetry OCD

Some clients with OCD have a concern about having things around them be “just
right,” doing things a certain way, or repeating actions until their bodies feel a certain
way. This has been termed the “not just right experience,” or NJRE (e.g., Coles, Frost,
Heimberg, & Rhéaume, 2003). The individual with this type of OCD may engage in
compulsions that include making sure things are orderly, such as lining up all shoes in
the closet the right way, making sure that canned goods are properly lined up and orga-
nized, or ensuring that all objects on a desk are placed “just right.” Exposures should be
designed to disrupt this “just right” experience.

Exposures for Ordering/Arranging/

“Not Just Right”/Symmetry

In-Office Exposures: ORDERING/ARRANGING/“NOT JUST RIGHT”/SYMMETRY

• Use imaginal exposure. Write a detailed story with your client about things being
a mess at home, record it, and have your client listen to it while imagining the mess.

• Write in a sloppy manner. Have your client write words on paper or a white board
in the office without erasing them or rewriting them to look perfect.

• Get a fake tattoo. Draw a fake tattoo on your client’s arm or hand (with her permis-
sion, or course) of numbers, letters, words, or shapes that are asymmetrical, messy,
or misspelled.

• Take an asymmetrical walk. Have your client walk around outside your office
building with one foot on the sidewalk and one foot on the street.

• Look at pictures. Have your client look at pictures online of messy houses or of
houses of people with hoarding disorder.

• Color pictures. Give your client something to color, such as a coloring book, and
have her do it in a messy way that includes going outside of the lines.

• Mess up your office. Encourage the client to make a “mess” in your office, such as
putting the books on your bookshelf out of order or upside down, tilting your pic-
tures or diplomas on the walls, and so on.

• Change shoelaces. Have your client take out one shoelace and lace it back in the
shoe incorrectly, such as by skipping holes in the shoe and having the remainder of
the shoelace be of different lengths.
Obsessive-Compulsive Disorder  159

Out-of-Office Exposures: ORDERING/ARRANGING/“NOT JUST RIGHT”/

SYMMETRY

• Rearrange closet or cabinets at home. Have the client rearrange closets at home
so that clothes or shoes are not lined up properly.

• Cut food. Encourage the client to prepare food at home, chopping the food at dif-
ferent lengths and widths. For example, instead of cutting a sandwich in half, have
the client cut it so one side has three-quarters of the sandwich and the other has
one-quarter of the sandwich.

• Make a mess in the home. Have the client deliberately cause chaos in a room of
the home.

• Have someone else make a mess in the home. Have the client choose a friend or
family member to make a mess in a room of the home. Encourage the client to watch
the mess being created without changing it.

• Get dressed in a sloppy way. Have the client put on clothes and wear them in an
uneven way, such as wearing two different socks or shoes, buttoning a shirt incor-
rectly, or wearing a hairstyle with hair pieces falling out of sections of a braid or
ponytail.

• Hang pictures. Have the client hang a picture in a crooked position in the bedroom.

• Change the light bulb. Have the client take one light bulb out of one of the two
bedside table lamps so the lighting is asymmetrical.

Safety Behaviors to Eliminate: ORDERING/ARRANGING/“NOT JUST RIGHT”/

SYMMETRY

Some clients will fix items around the house to make sure everything is properly aligned.
Encourage the client to take pictures of the rooms and the house and show them to you
periodically to make sure those behaviors have stopped at home. Also, some clients
might avoid rooms or places that are not neat or orderly, such as a messy basement or
garage in the home. Have the client purposefully spend time in the rooms or places she
has been avoiding.

Additionally, some clients with concerns about orderliness will ask others, such as those
who live in the home with the client, to tidy up “just so.” Encourage the client to eliminate
this behavior. If clients have a cleaning service, encourage them to eliminate or reduce
the frequency of visits.
160 The Big Book of Exposures

Checking-Based OCD
The individual who has OCD related to checking behaviors may have concerns
about safety that lead her to repeatedly check that the stove is turned off, the water is
turned off, or the doors or windows are shut and locked in the house to ensure an intruder
won’t break into the home. A subset of checking-based OCD involves individuals who
have to check and/or re-do what they read or write in order to be certain that it’s correct
or “perfect.”

Exposures for Checking-Based Fears

In-Office Exposures: CHECKING

• Use imaginal exposure. Write a detailed script with the client about leaving the
stove or sink on in her home and the consequences of this error. (See the sample
imaginal exposure script at the end of this chapter.)

• Create uncertainty. Go into the bathroom or kitchen area of your office with your
client and have her turn the water faucet on and off and walk away without knowing
whether it was completely turned off or not.

• Repeat feared phrases about uncertainty itself. Ask your client to repeatedly
state, “I will never know” about her obsessional fear.

• State the feared outcome aloud. Should a client be worried about having left the
stove on at home, for example, have her repeatedly state, “I left the stove on at
home” or “My house could be burned down by now.”

Out-of-Office Exposures: CHECKING

• Briefly leave the home while the stove is on. Encourage the client to leave the
stove on and go to the mailbox to check the mail. Then have the client increase the
amount of time spent out of the home, such as running a brief errand while baking
cupcakes.

• Run errands with the sink on. Have the client leave the sink dripping and go run
an errand close to home; slowly increase the time spent away from the house.

• Leave appliances on at work. Ask your client to leave the coffee machine on or
faucet running at her place of work.

• Create uncertainty. Have your client turn a water faucet, oven, or appliance on
and off quickly, and leave the home without checking.
Obsessive-Compulsive Disorder  161

In-Office Exposures: REREADING AND REWRITING

• Tackle reading or writing. Provide a paragraph or story for the client to read in
session while refraining from rereading. Alternatively, ask the client to write a brief
passage using a pen, rather than a pencil, so that she will be unable to erase mis-
takes easily. Whether reading or writing, encourage the client to deliberately make
“mistakes” such as skipping, misspelling, or mispronouncing words.

• Make things messy. Ask the client to write down letters, phrases, and sentences
without erasing and rewriting it to make it look “just right.” Ask her to then start
making it very sloppy on purpose. You can also ask her to write down phrases as
messily as she can and then you have to try to read it. You can say, “That handwrit-
ing is so messy; I can barely read it” or “You weren’t even trying at all here,” to help
increase the anxiety during the exposure.

• Give a “quiz.” Choose a paragraph from any book or article and ask the client to
read it quickly. You can even set a timer if the client has trouble finishing reading in
a given amount of time. You can then “quiz” the client on the material. The client may
have an urge to check back again and again in the same paragraph to make sure
that she comprehended all of the material and didn’t miss anything; discourage this
repeated checking.

Out-of-Office Exposures: REREADING AND REWRITING

• Make mistakes on purpose. Have the client do assignments from school or work
while making mistakes on purpose. You can print out worksheets from the Internet
(e.g., math worksheets) to help the client practice filling things in incorrectly without
rewriting.

• Read while having distractions. Ask the client to do reading assignments from
school or work while experiencing significant distraction, such as while playing loud
music through headphones or having the television turned on loudly while continuing
to read without rereading.

Safety Behaviors to Eliminate: CHECKING; REREADING AND REWRITING

For those who repeatedly check things for safety reasons, make sure that the client
refrains from having someone else check the stove, locks, or doors (whether or not the
client is checking herself).

Some clients whose checking-based OCD pertains to rereading or rewriting will be using
a tablet or computer to write things down to make it easier to edit and will avoid pen
and paper. Therefore, encourage the use of pen and paper when taking notes or com-
pleting homework assignments.
162 The Big Book of Exposures

CONCLUSIONS
Treatment of OCD, as with other anxiety-related disorders, is based largely on the process
of exposure. Safety behaviors, which in the case of OCD are known as compulsions,
should be eliminated as soon as possible in the process. Exposures to feared contami-
nants, risky situations, or imperfection are powerful tools in the OCD therapist’s reper-
toire, as are imaginal exposure to “forbidden” religious or sexual thoughts, or to fears of
harming one’s self or others. In the next chapter, we will provide various exposure ideas
for the treatment of different types of traumatic experiences.

CHAPTER RESOURCES
Reminder: These resources are also available to download and print from http://www.
newharbinger.com/43737.
Obsessive-Compulsive Disorder  163

Directions for Making an Elaborate Spirit Board

Items that you will need:
• A piece of cardboard or poster paper
• Glue
• Letters of the alphabet printed out
• Numbers 0–9 printed out
• The words “yes,” “no,” “hello,” and “goodbye” printed out
• Scissors
• A “planchette” (i.e., a small object that is needed for the spirit to write back to
you using letters on the board)

A spirit board is a “game” that some say can allow you to come into contact with spirits
(either good or bad). In this exposure you will create a board as an attempt to contact
a spirit. Sit down together and create a spirit board by gluing cutout letters and numbers
onto the board or poster paper. Once it is complete, put your planchette on the board.
Place your fingers on the planchette and see if you can communicate with a spirit by
asking questions aloud to spirits and seeing if the planchette moves to various letters and
numbers to answer your questions.

Simple Spirit Board

Directions: Use the printout provided to try to contact a spirit.

Item that you will need for the simple board: A “planchette” (i.e., a small object that
is needed for the spirit to write back to you using letters on the board)
164 The Big Book of Exposures
Obsessive-Compulsive Disorder  165

Example Imaginal Exposure Script—Self-Harm

I go into the bathroom and see a razor blade sitting on the bathroom counter. It was
as if it were left out just for me. I barely hesitate and then use the blade to swiftly cut
through the skin on my arm. I don’t stop with one cut and continue onto my leg. Fresh
blood pools at the surface. I knew the day would come where I would lose all control.
Without even a knock, the bathroom door opens and my family is standing right in
front of me. They scream and call 911. Shortly thereafter I hear the ambulances in
the distance. The sounds get louder and louder until I am surrounded by officers and
EMTs. I tell them my OCD took over and drove me to hurt myself. I am strapped into
a stretcher and brought straight to the psychiatric unit. They tell me I will be there a
long time with no visitors. They don’t believe me that I was never trying to kill myself.
I will be locked up forever and will never see my friends and family again.

Example Imaginal Exposure Script—Hit and Run

I get into my car to drive to work on this rainy day. I buckle up and put on some
music for my commute. I am driving along when I hear a scream and feel a bump
underneath my tires. I think, Did I hit someone? I glance in the rearview mirror to see
but there doesn’t appear to be anything there. Then again, it is very foggy due to the
rain so I can’t be 100% sure. I have the urge to turn my around car to check, but I
think it must all be in my head. When I get out of the car as I arrive at work, I see
some red stains on my tires. I worry that it might be blood but try to reassure myself
that I likely hit a dead animal that was already in the road. I head into work trying
not to think about it. All of a sudden, the door to the office opens and several police
officers are standing in front of me. They call me by name and tell me I am under
arrest. They put me into the police car and drive me to the station, where I am then
interrogated. The investigators tell me that I am in big trouble for leaving the scene of
an accident. Tears are streaming down my face as they tell me I killed a pedestrian.
My life is ruined and things will never be the same.
166 The Big Book of Exposures

Example Imaginal Exposure Script—Leaving the Stove On

I make some breakfast on the stove and get ready to leave. I am already running late.
I usually check the stove to make sure it is turned off before I leave the house, but this
time I forgot. I’m now too far from home to go back and check. I fear the house could
be in flames but try to dismiss the thoughts as just an overactive imagination. Still, I
can’t shake the thought and try to call some friends and family members to check on
the house while I am out just to make sure it is okay, but no one answers. My anxiety
starts to rise and my heart is pounding. I hear my phone ring and I look down to see
an unknown number. I pick up the call and it is the fire department in my town
calling to notify me that there has been a fire in my home and to come back
immediately. I jump into my car and drive home as fast as I can. Before I even turn
onto my street, I can already see the smoke in the distance and smell the strong smell
of fire. There are many firetrucks lined up on my street and firefighters working hard
to put out the flames that are bursting out of the windows of my home. I pull over to
the side of the road and get out of the car. I fall to the ground crying as I realize my
pets are in the home as well as all of my treasured items. I am fully to blame and will
never recover from this tragedy.
 CHAPTER 9

Acute Stress Disorder and

Posttraumatic Stress Disorder

In this chapter, we will begin with a brief overview of the two primary disorders related
to trauma, including discussions of diagnostic criteria and treatment considerations, and
then provide exposures to help your clients who have trauma-related disorders face their
fears. In addition, we will discuss safety behaviors to assess and eliminate for these
disorders.

WHAT ARE ACUTE STRESS DISORDER AND

POSTTRAUMATIC STRESS DISORDER?
Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are both psychi-
atric disorders entailing symptoms that emerge following a traumatic event. The main
distinction between ASD and PTSD is the length of time the symptoms persist. ASD
refers to acute trauma-related symptoms that last for less than one month following the
traumatic event, whereas in PTSD, which often follows ASD, the symptoms have per-
sisted for one month or more following the traumatic event (APA, 2013). Note that for
either diagnosis to be made, the disturbance must cause significant distress or impair-
ment in functioning and cannot be attributed to the effects of substance use or a medical
condition or other mental disorder.
Both ASD and PTSD, according to the DSM-5, involve exposure to actual or threat-
ened death, serious injury, or sexual violence. The individual either
1. directly experienced the event
2. witnessed the event happening to another person
3. heard of the event happening to a close family member or close friend, or
4. was exposed over and over to extremely horrific details of the event.

To diagnose ASD, the individual has to experience nine or more of the following
symptoms for a period of three days to one month after being exposed to the traumatic
event:
168 The Big Book of Exposures

Intrusive mental activity:

• Recurrent, involuntary, intrusive, and distressing memories of the event
• Recurrent, distressing dreams that are related to the event
• Dissociative flashbacks in which it feels as if the event is happening again
• Intense or prolonged psychological distress or strong physiological reactions to
cues that resemble the event

Negative mood symptoms:

• Persistent inability to experience positive emotions (e.g., happiness, satisfaction,
love)

Dissociative symptoms:
• Altered sense of reality (e.g., “out of body experience,” being in a daze, time
slowing down)
• Inability to remember an important aspect of the event, not due to head injury,
alcohol, or drugs

Avoidant symptoms:
• Efforts to avoid unpleasant memories, thoughts, or feelings related to the event
• Efforts to avoid external reminders (e.g., certain people, places, conversations,
activities, objects, or situations) related to the event

Symptoms of persistent hyperarousal:

• Sleep disturbance (difficulty falling asleep, difficulty staying asleep, restless
sleep)
• Irritable behavior and angry or aggressive outbursts, with little or no
provocation
• Hypervigilance or excessive scanning of the environment for threat
• Difficulty concentrating
• Exaggerated startle response

As noted above, PTSD is diagnosed when a person experiences trauma-related

symptoms lasting longer than one month following exposure to the trauma. Additionally,
in PTSD, rather than experiencing any nine or more of the symptoms listed above, the
individual must experience one or more intrusion symptom, one or both avoidance
symptoms, two or more symptoms of negative change in cognition or mood, and two or
more symptoms of altered arousal and activity, which can include reckless or self-destruc-
tive behavior.
An additional intrusive symptom often present in individuals with PTSD, but not
ASD, is having strong physiological reactions to cues that resemble the traumatic event.
Acute Stress Disorder and Posttraumatic Stress Disorder  169

Additionally, several symptoms of negative change in cognition or mood can be present

in PTSD but not ASD. These symptoms are as follows:
• Inability to remember an important aspect of the traumatic event, which is typi-
cally due to dissociative amnesia and not head injury or substance use
• Persistent and exaggerated negative belief or expectations about the self, others,
or the world (e.g., “No one can be trusted”; “The world is dangerous.”)
• Persistent distorted cognition about the cause or consequence of the traumatic
event that leads to self-blame or placing blame on others
• Persistent negative emotional state, such as fear, horror, anger, guilt, or shame
• Significant decrease in interest or participation in significant activities
• Feeling detached or estranged from others

Epidemiologic research suggests that most adults have experienced, witnessed, or

learned of a traumatic event in their lives (Breslau et al., 1998). Approximately 6% of
adults and adolescents have a lifetime history of PTSD (Kessler et al., 2012). Some of the
direct traumatic experiences that are often associated with PTSD include physical
assault, sexual assault, serious accidents, combat, and natural disaster. For most people,
traumatic experiences will not lead to the development or diagnosis of ASD, PTSD, or
another prolonged psychiatric disturbance. It’s important, therefore, not to assume
someone has ASD or PTSD based on exposure to a traumatic experience alone. However,
a subset of individuals who have experienced or witnessed a traumatic event will go on
to develop a trauma-related disorder.

Fear and Avoidance in Acute Stress Disorder/

Posttraumatic Stress Disorder
Fear and avoidance in ASD/PTSD can be of external or internal stimuli. Feared
external stimuli may include situations or activities that appear “risky,” such as driving on
a highway or walking down a dark street. They may also include situations or activities
that serve as reminders of the traumatic event; for example, a client with PTSD related
to a motor vehicle accident might feel distressed and subsequently change the channel
when an accident appears on TV, or may go to great lengths to avoid talking about the
traumatic event. Feared internal stimuli include the traumatic memories themselves.
People with ASD/PTSD often perceive their traumatic memories as threatening and
might believe statements such as “If I allow myself to remember my trauma, I’ll become
so upset that I won’t be able to handle it.” When traumatic memories elicit fear, there is
a natural tendency to try to suppress those thoughts by distracting oneself or using
various “numbing” techniques. The problem is that suppression of thoughts tends to
backfire, making those thoughts become even more intrusive and aversive (J. G. Beck,
Gudmundsdottir, Palyo, Miller, & Grant, 2006; Wegner et al., 1987).
170 The Big Book of Exposures

Important Considerations in the Treatment of Acute

Stress Disorder/Posttraumatic Stress Disorder
Though exposure-based therapy is efficacious for ASD (Bryant, Harvey, Dang,
Sackville, & Basten, 1998), it is important to note that “critical incident stress debrief-
ing” sessions—in which people (who often do not have ASD) are put into groups (often
compulsorily) and asked to share traumatic memories—may do more harm than good
(Rose, Bisson, Churchill, & Wessely, 2001; van Emmerik, Kamphuis, Hulsbosch, &
Emmelkamp, 2002). Such sessions may disrupt the normal processing of trauma, “medi-
calize” normal trauma reactions and create an expectation of illness, and result in sec-
ondary traumatization (Bisson, 2003). We therefore caution that any early exposure-based
interventions for trauma reactions be (a) completely voluntary, (b) done on an individual
basis, and (c) limited to people with ASD.
Sometimes, PTSD occurs as a single diagnosis. However, comorbid anxiety disor-
ders, depressive disorders, and substance use disorders are common and need to be taken
into consideration. In some severe cases, particularly when recurrent trauma is experi-
enced in childhood, the person experiences not only the symptoms of PTSD but also
significant emotion regulation difficulties, disturbances in relational capacity, alterations
in attention and consciousness (e.g., dissociation), adversely affected belief systems, and
somatic distress or disorganization. Such cases have been called complex PTSD (Cloitre
et al., 2009). Exposure can and should play a role in these clients’ treatment as well,
though they will often require some training in emotion regulation skills (e.g., Linehan,
2014) before launching into exposure.

BEHAVIORAL TREATMENT FOR ACUTE STRESS

DISORDER/POSTTRAUMATIC STRESS DISORDER
At the end of this chapter, we have included an imaginal exposure script for you to
use with your client as a template. Your client can alter the script in order to individualize
it since traumatic experiences are, in fact, so personal and specific to the event that
occurred. For ease of use, we have categorized the exposure lists in this chapter based on
five types of trauma:
1. Posttraumatic fears related to physical assault
2. Posttraumatic fears related to sexual assault
3. Posttraumatic fears related to accidents
4. Posttraumatic fears related to combat
5. Posttraumatic fears related to disasters
Acute Stress Disorder and Posttraumatic Stress Disorder  171

Posttraumatic Fears Related to Physical Assault

Physical (nonsexual) assault may take the form of muggings, beatings, shootings,
stabbings, or threats of violence. PTSD stemming from physical attack is significantly
more common in women, with 21% of women versus 2% of men who were physically
attacked meeting criteria for PTSD (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).

Exposures for: Physical Assault-Related Fears

In-Office Exposures: PHYSICAL ASSAULT-RELATED FEARS

• Create an imaginal exposure script of the traumatic event. Ask the client to write
a narrative of the traumatic event. If the client cannot tell the entire story at once,
writing down an aspect of it and reading it repeatedly can be a first step. You can
also ask your client to record the narrative onto a smartphone or other recording
device. When conducting imaginal exposure, we generally recommend encourag-
ing the client to use present-tense language (e.g., “Now he is punching me” instead
of “He punched me”) and to include as much detail as possible, including what the
client is seeing, hearing, smelling, feeling, tasting, and thinking. These procedures
help the client access the cognitive and affective representations of the trauma
memory, making the memory more vivid and the exposure more effective. (See the
example script at the end of the chapter.)

• Watch videos of physical assault. Depending on the client’s fears, this could start
with online videos of boxing matches, progressing to street fighting and other forms
of violence.

• Look at pictures of injuries occurring to others. With your client, conduct an

online search for people who have been in a fight resulting in black eyes, missing
teeth, or other injuries that might stem from being physically assaulted.

• Listen to sounds of the traumatic experience. Conduct an online search with your
client of sounds related to the event that might be anxiety provoking. Then have the
client repeatedly listen to the audio recordings of people crying, yelling, or
screaming.

• Look at pictures of the actual assault. Have your client look at newspaper articles,
mugshots of the perpetrator, or pictures of injuries from the client’s assault if these
are available.
172 The Big Book of Exposures

Out-of-Office Exposures: PHYSICAL ASSAULT-RELATED FEARS

• Listen to the imaginal exposure recording. Having already recorded a detailed

narrative of the traumatic event in session, ask the client to listen to the recording on
a daily basis at home. Have the client later listen to the recording while looking at
pictures of assault or injury (either online or pictures of the actual assault).

• Watch scary movies. Ask your client to watch violent television shows or movies that
the client has previously avoided.

• Go into crowded places. Have your client go to crowded places, such as to opening
night of a big box office movie, to the theater, or to a sports event. This can be chal-
lenging because the client can’t constantly scan for safety as there is so much going
on in those venues.

• Interact with “scary” people. Here, the clinician and client must use their best
judgment. Our aim is not to put the client in real danger. Rather, our goal is to have
the client confront things that are scary, but not actually dangerous. We’re not
saying, therefore, that the client should walk through a bad part of town alone at
night holding a wad of cash. But it may be possible to have the client interact with
strangers or people who remind the client of the trauma. For example, if the client
was assaulted by a tall man (and now fears tall men in general), it can be helpful to
arrange experiences in which the client encounters other (safe) tall men.

Safety Behaviors to Eliminate: PHYSICAL ASSAULT-RELATED FEARS

Some clients who have experienced physical assault will keep an exaggerated amount
of distance between themselves and other people (e.g., remaining far enough that the
other person cannot touch them). Encourage closer proximity to others.
Acute Stress Disorder and Posttraumatic Stress Disorder  173

Posttraumatic Fears Related to Sexual Assault

Sexual assault, like all traumatic experiences, can occur in adulthood or in child-
hood. Among victims of adult rape, 46% of women and 65% of men meet criteria for
PTSD. Among victims of child molestation, 25% of women and 12% of men meet criteria
for PTSD (Kessler et al., 1995).

Exposures for Sexual Assault-Related Fears

In-Office Exposures: SEXUAL ASSAULT

• Use imaginal exposure. Ask the client to record a narrative of the traumatic event
onto his smartphone or other recording device. For details, see “In-Office Exposures:
Physical Assault-Related Fears” above. In cases of repeated sexual assault, start
with a traumatic memory that the client perceives as aversive yet manageable; over
time, work up to more strongly aversive memories.

• Read accounts of sexual assault survivors. Have your client go online and read
first-hand accounts written by people who have survived sexual assault.

• Lie on the ground. You can ask your client if he is willing to lie down on the ground
and then work up to having others hover over him.
174 The Big Book of Exposures

Out-of-Office Exposures: SEXUAL ASSAULT-RELATED FEARS

• Listen to the imaginal exposure recording. Having recorded a detailed narrative

of the traumatic event in session, ask the client to listen to the recording on a daily
basis at home.

• Talk about the assault. Your client might be ready to talk to others about the
assault with family or trusted friends, or as part of a support group.

• Watch movies or TV shows that include depictions of sexual assault. Movies

such as The Prince of Tides, American History X, The Girl with the Dragon Tattoo, and
I Spit on Your Grave and TV shows such as 13 Reasons Why (Season 1, episodes 9
and 12; Season 2, episode 13) have rape scenes of varying degrees of graphicness
and brutality. Review these first before viewing them with the client.

• Interact with “scary” people. Again, our goal is never to create an objectively
dangerous situation for the client. But we can identify whether the client is avoiding
certain people, or certain kinds of people, who remind him of the trauma. For
example, some sexual assault survivors might avoid men in general or people of the
same age or race as their assailants. These would be viable targets for in vivo
exposure.

• Give or get hugs. Your client may be willing to hug or get close to other people,
such as friends or family members. Even if a friend or family member did not assault
him, the client still may avoid getting close to any person. Have the client start by
giving or receiving a quick hug and work up to a longer one.

• For female clients: Resume yearly gynecological exams. Following a sexual

assault, your client may have stopped getting routine exams. If so, encourage her to
resume this.

• Go on a date. If your client is single and has avoided dating for a long time, he can
try going on a date. If the client is not ready to date, he can go on a dating website
as an exposure to start talking with others who he may be interested in. This will help
him get the ball rolling again with dating even if it does not lead to a date.

• Visit the location of the assault. Ask the client to visit the place where the sexual
assault occurred, if possible.

Safety Behaviors to Eliminate: SEXUAL ASSAULT-RELATED FEARS

PTSD is a significant risk factor for substance abuse, and clients with sexual assault
trauma may be at particularly elevated risk. Encourage abstinence from substances
during exposure therapy and consider augmenting exposure therapy with substance
abuse treatment if necessary.
Acute Stress Disorder and Posttraumatic Stress Disorder  175

Posttraumatic Fears Related to Accidents

Nine percent of women and 6% of men who have experienced a serious accident
meet criteria for PTSD (Kessler et al., 1995). Here, we focus on motor vehicle accidents,
which are the most common form of serious accident (Breslau et al., 1998). However, you
can tailor these suggestions to fit the client’s traumatic experience.

Exposures for Accident-Related Fears

In-Office Exposures: ACCIDENT-RELATED FEARS

• Use imaginal exposure. Ask the client to record a narrative of the traumatic event
onto his smartphone or other recording device. For details, see “In-Office Exposures:
Physical Assault-Related Fears” above.

• Listen to audio clips of car crashes. Do an online search with your client for “car
brakes sound effects” to hear the sound of screeching brakes. Search for “car crash
sound effects” to hear the sound of a collision.

• Hold a mental image. Ask your client to pick a “scene” from the accident and
picture that scene with his eyes closed.

• Read accounts of accidents. Go online with your client and search for news stories
about accidents that are similar to that experienced by the client.

• Watch video clips. Conduct online searches with your client for car accidents and
watch videos of car crashes. Find the aspects of the video clips that are most anxiety
provoking and have the client watch those repeatedly.
176 The Big Book of Exposures

Out-of-Office Exposures: ACCIDENT-RELATED FEARS

• Listen to the imaginal exposure recording. Having recorded a detailed narrative

of the traumatic event in session, ask the client to listen to the recording on a daily
basis at home.

• Visit the accident location. The client can visit the location of the accident and
practice recalling the details of the event.

• Drive. Encourage the client to practice driving on his own, first in relatively low-
threat situations such as quiet neighborhoods, then in higher-traffic areas or high-
ways. Finally, the client should drive through the site of the accident repeatedly.

• Drive with accident sounds playing. The accident sounds described above (see
“Listen to audio clips of car crashes”) can be burned to a CD or loaded onto a
smartphone. Have the client play them over and over again while driving—to the
extent that it is objectively safe to do so.

• Talk about the person who died. If someone died during an accident, work with
your client to talk about the person with others (either those who knew the deceased
person or those who did not), look at pictures of the person, visit places that remind
him of the person, or visit the person’s grave.

Safety Behaviors to Eliminate: ACCIDENT-RELATED FEARS

When clients with PTSD get back on the road, they may drive excessively slowly, some-
times even keeping their flashers on. In addition to being a safety behavior, this can also
be dangerous. Encourage the client to keep up with traffic. Some clients will also “white-
knuckle” the steering wheel as a means of increasing perceived control. Suggest a more
relaxed grip.

Listening to the radio (thereby distracting oneself from anxiety) can serve as a safety
behavior for some clients. In such cases, encourage driving in silence or with the expo-
sure recording playing. On the other hand, for some clients, driving in a mildly distracted
state (e.g., with the radio on) could be an exposure hierarchy item, in which case we
would suggest having the radio on. Again, as is the case with many of the disorders
reviewed in this book, the therapist’s aim is to reverse the existing pattern of behavior:
approach what is avoided, and stop what is comforting.
Acute Stress Disorder and Posttraumatic Stress Disorder  177

Posttraumatic Fears Related to Combat

Among combat veterans, a staggering 39% meet criteria for PTSD (Kessler et al.,
1995). To date, most of the epidemiologic research on combat-related PTSD has been in
male veterans, though preliminary evidence suggests that combat-related PTSD is
common in female veterans as well, perhaps even exceeding the risk in male veterans
(Xue et al., 2015).

Exposures for Combat-Related Fears

In-Office Exposures: COMBAT-RELATED FEARS

• Use imaginal exposure. Ask the client to record a narrative of the traumatic event
onto his smartphone or other recording device. For details, see “In-Office Exposures:
Physical Assault-Related Fears” above. For many combat veterans, there will be
several traumatic memories to consider. Start with a memory that the client per-
ceives as aversive yet manageable; over time, work up to more strongly aversive
memories.

• Use virtual reality. If you have VR equipment, the client can experience the sights
by being able to look around in the virtually real world using the headset and hear
sounds (e.g., helicopters, explosions) of a combat zone. The Virtually Better system,
for example, has modules for Vietnam and Iraq/Afghanistan.

• Listen to sounds of fireworks or explosions. Do an online search for sounds of

explosions or fireworks, especially bottle rockets, and listen to those repeatedly in
the office together. Work toward listening to them with the volume increasingly
louder.

• Watch movie clips of combat. Online, you can find combat scenes for your client
to watch from movies such as Saving Private Ryan, Platoon, American Sniper, and
Black Hawk Down, as well as several news clips showing combat in Iraq, Afghanistan,
and elsewhere.

• Sit with back to door. Have your client sit in your office with his back to the door.
Then have the client do this in other places in your office area, such as the waiting
room, so that he can’t scan the area as well (or at all).
178 The Big Book of Exposures

Out-of-Office Exposures: COMBAT-RELATED FEARS

• Listen to the imaginal exposure recording. Having recorded a detailed narrative

of the traumatic event in session, ask the client to listen to the recording on a daily
basis at home.

• Sit in a crowded room. Have your client go out to a movie theater or restaurant
and choose a seat where he can’t have his back to the wall. You can also ask your
client to sit in the front of a room or the front of public transportation so that people
are behind him.

• Interact with “scary” people. Some veterans feel fearful around people of the
ethnic and racial backgrounds reminiscent of their traumatic experiences. Encourage
the client to visit ethnic neighborhoods, shops, and restaurants and to interact with
others there.

• Attend a veteran’s counseling group. A veteran’s counseling group is not only a

helpful way to obtain much-needed social and emotional support, but it also can be
a way for your client to begin talking about combat experiences.

• See fireworks. Ask the veteran to attend a fireworks show, such as on the 4th of
July, in order to come in contact with the loud noises that resemble gunshots, as well
as to be in crowded areas.

Safety Behaviors to Eliminate: COMBAT-RELATED FEARS

Rates of substance abuse are high in veterans with PTSD, and use of substances (includ-
ing alcohol and marijuana) may serve as a means of avoiding painful memories and
emotions. Encourage the client to avoid the use of substances during exposure and con-
sider referral for substance abuse treatment if indicated.

Some clients with combat-related PTSD will scan rooms, movie theaters, or restaurants
while inside as a way to check that everything is safe. Encourage the client to try going
out without scanning. This can include going for walks, going into stores, or sitting in
restaurants.
Acute Stress Disorder and Posttraumatic Stress Disorder  179

Posttraumatic Fears Related to Disasters

Five percent of women and 4% of men who are exposed to a disaster meet criteria for
PTSD (Kessler et al., 1995). Fires, floods, earthquakes, and other natural disasters are all
risk factors for the development of PTSD.

Exposures for Disaster-Related Fears

In-Office Exposures: DISASTER-RELATED FEARS

• Use imaginal exposure. Ask the client to record a narrative of the traumatic event
onto his smartphone or other recording device. For details, see “In-Office Exposures:
Physical Assault-Related Fears” above.

• Read stories. Conduct an online search with your client for natural disasters. If pos-
sible, see if you can find stories or articles related to the natural disaster your client
experienced.

• Watch movie clips of disasters. The Internet offers a number of video clips of
earthquakes, tornadoes, hurricanes, fires, and more to watch with your client in
session. Focus on the parts of the clip that lead to the highest anxiety in your client
and replay those parts repeatedly.

Out-of-Office Exposures: DISASTER-RELATED FEARS

• Listen to the imaginal exposure recording. Having recorded a detailed narrative

of the traumatic event in session, ask the client to listen to the recording on a daily
basis at home.

• Watch movies that include depictions of disasters. Several movies, including San
Andreas, Twister, Backdraft, and The Day After Tomorrow have realistic depictions of
natural and human-made disasters. Have your client watch these movies at home.
180 The Big Book of Exposures

Safety Behaviors to Eliminate: DISASTER-RELATED FEARS

When watching a video clip or movie, your client might be distracted, peaking at it
through his fingers, and so on. Ask the client to avoid using this safety behavior and
instead to be fully engaged in the scenes. You can ask the client to fully describe the
scene he is watching to prevent any subtle avoidance.

When writing the imaginal exposure script, some clients may want to hold back from
putting in all of the gory details. Ask the client to make sure he has included all parts,
including the most catastrophic thoughts, feelings, and scenes imaginable. You can go
line by line over the story with your client and ask if any detail is missing that should be
added to prevent the client from engaging in avoidance behavior.

As always, encourage the client to avoid the use of substances before or during expo-
sure, and consider a referral for substance abuse treatment if indicated.

CONCLUSIONS
PTSD and ASD are associated with two main categories of feared stimuli: external and
internal. External feared stimuli can be situations or activities that are reminiscent of the
traumatic event (e.g., news stories about assault), or they can be situations or activities
that the client perceives as risky (e.g., driving at night). Internal feared stimuli are the
traumatic memories themselves (e.g., one’s memory of combat experiences) as well as the
associated emotions. That is, people with PTSD and ASD perceive threats from both
outside and inside themselves. In this chapter, we’ve provided you with some ideas about
how to address both of these categories of fear, using in vivo exposure to feared external
stimuli and detailed imaginal exposure to feared trauma memories. The aim, as with all
exposure therapy, is to help the client recognize that these stimuli are not actually dan-
gerous; in PTSD and ASD, we are also trying to help the client put the trauma into its
proper perspective by disrupting vicious cycles of avoidance and thought suppression.
In the next chapter, we will discuss how to use exposure to treat clients with illness
anxiety disorder. The chapter will provide various ideas for exposure for clients who
avoid medical information as well as for those who tend to seek such information out.
Acute Stress Disorder and Posttraumatic Stress Disorder  181

CHAPTER RESOURCES
Reminder: These resources are also available to download and print from http://www.
newharbinger.com/43737.

Example Imaginal Exposure Script—Physical Assault

I am walking home from the store late at night when I hear footsteps coming closer to
me. Without turning around, I quicken my pace and can see my car parked up ahead
in the distance. Almost there. I reach into my pocket to grab my keys so that I can
easily unlock my door, when all of a sudden I get hit from behind. I fall to the ground
and can taste blood in my mouth. I see multiple pairs of shoes near my head, knowing
that I am outnumbered. At least one person is holding me down while someone else is
going through my pockets and belongings. I feel something cold pressed against my
head and I fear it is a gun. I try not to move and tell them to take whatever they
want. They tell me to shut up and I get kicked in my side as I yell in pain. I lose focus
on the things around me and wonder when someone will come to help me. My eyes
begin to close and I lose consciousness.

Example Imaginal Exposure Script—Accident-Related PTSD

I’m driving home from work and it’s raining heavily. I can barely see the road. I’m
feeling nervous and I’m gripping the steering wheel. It feels like I’m going too fast, like
the car is going to go out of control. I can just feel like something is about to happen.
The cars are coming in the opposite direction, and I can see the glare of their
headlights through the rain on my windshield. They seem like they’re awfully close to
me. I want to get off the road; I tell myself I shouldn’t be driving in this weather. All of
a sudden an oncoming car swerves into my lane and it all happens too fast for me to
react. I hit the car head on and I can hear a sickening crunch of metal and the sound
of breaking glass. I black out for a second, maybe longer, and when I come to, the
airbag has deployed and I can’t see anything in front of me. It’s so hard to breathe.
I can see that there’s blood on the airbag and I realize that my nose is bleeding. My
chest is throbbing from the seat belt and it feels like I broke a rib. My heart is going
a mile a minute. I try to open the door but I can’t budge it. As I try, I feel a stabbing
pain in my wrist and in my head. I can barely see through the window, but I can see
enough to know the driver of the other car appears to be in bad condition. I can see
blood smeared across his window. I smell gasoline from the accident fill the air. It’s
strangely quiet and all I can hear is the sound of the rain falling on the roof of the car.
182 The Big Book of Exposures

Example Imaginal Exposure Script—Combat-Related PTSD

I am riding in the Humvee with three of my comrades. I am in full gear in 100 degree
heat, sweating profusely, and my heart is pounding so loudly I am afraid even the
enemy can hear it. Every bump in the road I fear could be an improvised explosive
device. I’ve seen it happen too many times. Eventually we near our destination. All of
a sudden there is a deafening explosion that rocks not only the vehicle but my entire
body. My hearing is going out and I am disoriented. There is a piercing ringing. As
the smoke clears, I look around to assess the scene and help those who may be
wounded. Clutching my gun tightly, I go to my buddies. Some of them are still in the
vehicle and are severely injured, while others are now on the side of the road, limp and
bleeding profusely. I go to my best friend and hold him in my arms and tell him to
hang on and make it until the medic arrives on scene. I can tell he is fading as his eyes
begin to close. He dies in my arms. I hold him, looking around and wondering why
this happened to him and not me. The guilt and sorrow I feel is unbearable.
 CHAPTER 10

Illness Anxiety Disorder

Illness anxiety disorder, derived from the older diagnosis of hypochondriasis, is a new
diagnosis in the DSM-5 (APA, 2013). This chapter will provide an overview of illness
anxiety disorder and its treatment. In addition, we will provide detailed exposures to help
your clients who have anxiety related to health conditions face their fears through in
vivo, interoceptive, and imaginal exposure.

WHAT IS ILLNESS ANXIETY DISORDER?

The DSM-5 (APA, 2013) lists the criteria for illness anxiety disorder as:

A. A preoccupation that one has, or will acquire, a serious disease.

B. The person has no more than mild somatic symptoms. If a medical condition
or risk of a medical condition is present, the person’s preoccupation is clearly
excessive to the actual illness or risk.

C. The person is highly anxious about his or her health and is easily alarmed
about his or her health status.

D. Behavioral features can include excessive health-related behaviors or maladap-

tive avoidance.

E. The anxiety is persistent (e.g., six months or more).

F. The preoccupation is not better explained by another mental disorder.

The prevalence of illness anxiety disorder is not clear, in part because this diagnosis
first appeared in the most recent DSM and therefore has not been the subject of major
epidemiologic research. Estimates of the prevalence of hypochondriasis, the DSM-IV
(APA, 2000) diagnosis from which the illness anxiety disorder diagnosis was partially
derived, range from 0.2% (Looper & Kirmayer, 2001) to 5% (Faravelli et al., 1997).
184 The Big Book of Exposures

Fear and Avoidance in Illness Anxiety Disorder

In the diagnostic criteria, listed above, we see that illness anxiety disorder entails a
fear of contracting a disease or having an underlying disease or condition that may have
gone undiagnosed, despite repeated testing and frequent visits to primary care as well as
specialists’ offices. An individual with this fear will often be aware of any changes in
bodily sensations and interpret these sensations as catastrophic in nature (e.g., slight
tingling in an extremity means an onset of multiple sclerosis; a headache is interpreted as
a brain aneurism, or a new mole or splotch on the arm is feared to be skin cancer). These
bodily sensations or changes are not imagined and are, in fact, very real. It is therefore
important to relay to your client that you understand that these symptoms are not “all in
her head.”
Individuals with illness anxiety will often seek repeated testing to ensure they are
okay. Despite reassurance from doctors and negative tests results, an individual with
these concerns may seek out confirmation from other doctors or go to specialists to con-
tinue to rule out a serious condition. These doctor visits and testing can become very
costly as lab work, CT scans, X-rays, and MRIs are not inexpensive.
Conversely, some other clients with illness anxiety have an avoidant coping style, in
which they avoid doctors’ visits or other health-related information so that they do not
receive “bad news” or are not reminded of their perceived illness or illness risk. Thus,
there are two categories of behavioral dysfunction in illness anxiety: information-seeking
and information-avoidant.

Important Considerations in the Treatment of Illness

Anxiety Disorder
The construct of illness anxiety disorder overlaps significantly with other anxiety-
related disorders. Clients with panic disorder, for example, may also fear a medical catas-
trophe such as a heart attack. However, in panic disorder, these illness-related fears
usually occur only when the client is having a panic attack, rather than being an ongoing
concern. Clients with OCD may fear contracting a disease, usually via contamination.
In illness anxiety disorder, on the other hand, the person tends to be preoccupied not
with a concern about contracting a disease, but rather that she has a disease that has
been undiagnosed or an underlying vulnerability to develop a disease.
The distinction between information-seeking and information-avoidant illness
anxiety disorder is an important one because in exposure therapy, our aim is to reverse
the existing pattern of behavior. That is, for information-seeking clients, we want them to
stop their safety behaviors and tolerate the uncertainty of not knowing whether or not
they have a disease. For information-avoiding clients, we want to expose them to infor-
mation that they perceive as threatening.
The core fear of clients with illness anxiety may be death, but it may also be about
being in pain, dealing with uncertainty, or seeing loved ones witness their deterioration.
It is important to figure out your client’s core fear so that you can target it directly in
treatment.
Illness Anxiety Disorder 185

BEHAVIORAL TREATMENT FOR ILLNESS

ANXIETY DISORDER
In addition to providing exposures that can be applied broadly to clients with illness
anxiety disorder, we have also, where appropriate, listed specific exposures that can be
used for clients with the following common concerns:

Cardiac—Individuals with illness anxiety may have concerns about having a heart
attack or underlying heart disease. They may monitor their blood pressure, be
overly cautious about engaging in physical activity, and make excessive trips to the
doctor.

Cancer/Tumors—Cancer is another common concern among individuals with

illness anxiety. This fear may include having cancer that has gone undiagnosed
and is getting worse. It can include any type of cancer, including breast cancer, a
tumor, or skin cancer. Information-seeking clients may excessively check their skin
or feel for spots in the body, such as by doing breast self-exams. Conversely,
information-avoidant clients might avoid checking themselves or getting any kind
of screening at all.

HIV/AIDS—Having undiagnosed HIV/AIDS can be a concern for those with

illness anxiety. A client with this fear may avoid intimacy with others or may be
overly cautious (e.g., going to get HIV testing regularly).

Degenerative neurological disorders—Degenerative neurological disorders, such

as multiple sclerosis (MS) or amyotrophic lateral sclerosis (ALS), can be cause for
concern for those who have illness anxiety. Individuals with this fear may be
concerned about muscle twitching in the extremities, weakness in an area of the
body, or changes in vision.

Insanity—Individuals with illness anxiety may fear having a serious mental health
condition. For example, a client with this fear may be concerned about losing her
mind or developing a severe mental disorder, and thus potentially being thrown
into an “insane asylum.” Many movies depict frightening scenes of being locked up
in a padded cell, and these kinds of images may come to mind when one is con-
cerned with becoming mentally ill.

Remember, our general strategy is to reverse the existing pattern of behavior. So for
information-avoidant clients, we want to lead them to more and more “scary” informa-
tion. For information-seeking clients, we want them to put the brakes on their safety
behaviors. This distinction is important as you do not want to assign an exposure of
going to the doctor for a check-up to an information-seeking client, for example.
Although illness anxiety disorder is diagnostically distinct from panic disorder, in
both conditions, as noted above, clients can fear catastrophic illness (e.g., a heart attack
or stroke). Interoceptive exposure, therefore, can be useful in the treatment of both
186 The Big Book of Exposures

disorders. We have included exposures to help target these fears; however, we also
encourage you to reference chapter 6 on panic disorder for a more exhaustive list that
outlines additional interoceptive ideas for clients.
Included at the end of the chapter are a variety of imaginal exposure scripts for spe-
cific concerns related to illness anxiety. Use these with your client as a template, adding
to and adjusting them to make the script more individualized to the client. Just as in
chapter 6, which contains a sample letter to send to the client’s physician to obtain con-
firmation that interoceptive exposures are safe for the client, we encourage you to be in
contact with the physician prior to beginning the interoceptive illness anxiety exposures
as well.
Illness Anxiety Disorder 187

Exposures for Illness Anxiety

In-Office Exposures: ILLNESS ANXIETY

• Conduct interoceptive exposures. Because people with illness anxiety disorder

often fear catastrophic medical events, we recommend that you and the client prac-
tice facing the bodily sensations that elicit fear. Below are some examples of intero-
ceptive exposures for various types of health concerns:
• Cardiac concerns: Have the client run in place, walk quickly, go to the gym,
drink caffeine, and do what she can to get her heart rate up. Ask your client to
drink espresso or an energy drink, which may lead to a racing heart. Refer to
chapter 6 for additional ideas to get the heart racing or pounding.
• Degenerative neurological disorders (e.g., MS, ALS): Exercises such as hyper-
ventilation and keeping the arms raised can lead to tingling sensations, which
may trigger fears of a degenerative neurological illness.
• Insanity: Exercises that induce depersonalization or derealization can be used,
such as staring at oneself in a mirror, being in a room with a strobe light, or
staring at light coming through a venetian blind. We also recommend having the
client spin in place while standing or sitting in a chair with wheels to feel
disoriented.

• Read scary stories. Do online searches with your client to find stories about people
who have experienced or died from the feared medical condition. Ask your client to
repeatedly re-read the parts of the story that evoke the most anxiety.

• Say scary phrases. Have your client repeat feared phrases such as “I have a brain
tumor,” “I have AIDS,” “I am going insane,” and so on.

• Create an imaginal exposure script. Create a detailed script about experiencing,

and even dying from, the feared medical condition. (See the imaginal exposure
scripts at end of this chapter.)

• Get “bad” news. Practice giving the client bad medical news. Review with the client
beforehand the fact that you’re planning to give her bad news—we’re not looking
to fool the client. Some examples include:
• Cardiac concerns: Set up an exposure with your client in which you measure her
blood pressure or heart rate in session and tell her that it is abnormally high
and, therefore, very concerning.
• Cancer/Tumors: Role-play giving your client the bad news that she has stage 4
cancer.
• HIV/AIDS: Role-play giving your client the news that she has now been diag-
nosed with AIDS and has X amount of years to live.
188 The Big Book of Exposures

• Degenerative neurological disorders: Make a list of symptoms of your client’s

feared disorders and print it out. Look at the paper seriously and then say, “You
do appear to have multiple sclerosis, as you have most of the symptoms needed
for diagnosis.”
• Insanity: Tell the client, “It is my opinion that you are clinically insane.” Remember,
this needs to be planned out and conducted collaboratively with the client.
We’re not looking to fool her; we just want the client to practice hearing the
scary words.

• Write a self-obituary. Ask your client to write her own obituary, indicating that she
died from the feared illness. You can then read the obituary to the client and also
ask her to read it aloud. To make the exposure more intense, ask the client to read
it (or listen as you read it aloud) while looking at pictures of coffins, cemeteries, or
funeral processions.

Out-of-Office Exposures: ILLNESS ANXIETY

• Conduct interoceptive exposures. These interoceptive exposures can be con-

ducted out of the office:
• Cardiac concerns: Ask your client to go to a steam room or other area that might
make her experience feared sensations such as feeling hot or sweaty. When
appropriate and not dangerous to do so, your client can sit in the car on a summer
day with the windows rolled up for a few minutes to try to create the feared sen-
sation of being overheated and having a racing heart due to the hot conditions.
• Degenerative neurological disorders (e.g., MS, ALS): Interoceptive exposures
that elicit a tingling sensation in the extremities can be helpful, including hyper-
ventilating or keeping the arms elevated.
• Insanity: The client can do exercises that induce depersonalization or dereal-
ization, such as staring at oneself in a mirror, being in a room with a strobe light,
or staring at light coming through a venetian blind. The client should practice
doing this while out of the office, such as in the parking lot of a state hospital or
while home alone and watching a movie about mental illness, to make it more
anxiety provoking.

• Watch movies. Ask your client to watch online video clips, movies, or television
shows related to the feared medical condition. Watching it while home alone will
make it even more challenging. Have your client pay special attention to the parts
of the movie that create the most anxiety and replay those parts repeatedly. Some
movies that might be effective include:
• Cardiac concerns: The Widowmaker
• Cancer/Tumors: A Walk to Remember, The Fault in Our Stars, Dying Young,
Terms of Endearment, and Stepmom
Illness Anxiety Disorder 189

• HIV/AIDS: Philadelphia, Rent, The Normal Heart, and The Hours

• Degenerative neurological disorders (e.g., MS, ALS): The Theory of Everything,
Gleason, and I Am Breathing
• Insanity: A Beautiful Mind, Split, Shutter Island, One Flew Over the Cuckoo’s
Nest, and Girl, Interrupted

• Read obituaries. Have your client read obituaries while at home, as she may come
across some stories in the newspaper or online about someone who died from the
feared medical condition.

• Visit a cemetery. Go with your client to a cemetery or ask her to do this outside of
the session if she has fears about death related to a medical illness. First, have your
client practice driving by the cemetery, then work toward driving through the cem-
etery, getting out of the car, and then later walking around and looking at head-
stones. You can have your client bring along the imaginal exposure script she wrote
and read it while sitting in the cemetery.

• Pretend to have the feared illness. Strategies to have your client pretend to be
sick in your office include:
• Cardiac concerns: Encourage the client to clutch her chest or slur her words, to
mimic signs of a heart attack or stroke.
• Cancer/Tumors: The client can wear a head scarf, as is often worn by chemo-
therapy patients to conceal hair loss.
• Insanity: Purchase a straitjacket costume (often sold for Halloween) from an
online retailer and have the client wear it in session. To make the exposure more
challenging, you can ask your client to wear it while she listens to a recording of
the imaginal exposure script or while watching a movie of someone who has
been institutionalized due to severe mental illness. Alternatively, have your client
go to a store or other public area and talk to herself aloud.

• Visit the hospital or volunteer. The client can volunteer to help others with the
feared medical condition. Generally, this would require your client to register as a
volunteer with the hospital. Alternatively, it might be helpful (assuming you have
adequate permission) for your client to simply sit in the waiting room of a medical
unit specializing in the feared illness (e.g., a cardiac clinic, an oncology unit).

• Get avoided medical tests. Information-avoidant clients will often avoid needed
medical tests for fear of getting bad news. Therefore, encourage these clients to
obtain tests, as shown for specific concerns below:
• Cardiac concerns: Clients can ask their physician to check their blood pressure
or administer an EKG.
• Cancer/Tumors: Clients can visit a dermatologist to get checked for skin cancer.
• HIV/AIDS: Clients can visit their physician or a reproductive health clinic to be
tested for HIV and other sexually transmitted diseases.
190 The Big Book of Exposures

Safety Behaviors to Eliminate: ILLNESS ANXIETY

Many clients will avoid any activity that may change their bodily sensations (e.g., racing
or pounding heart), such as exercise, sex, or caffeine. Therefore, make sure that these
activities are reintroduced as soon as possible. Some clients say they used to love to
drink coffee but gave it up to prevent anxiety. Help the client get back to the previous
routines before anxiety became so prominent.

Clients with illness anxiety may seek reassurance from family members, friends, or
doctors. Ask your client to refrain from seeking reassurance from others. In addition, if
you meet with friends and family members, you can have them answer the question that
the client poses to them once and then each time after that say, “I already told you what
I thought, and I am not going to tell you again as I do not want to make your anxiety
worse in the long run.” Later on (and with the client’s permission), you can have the family
member refrain from giving reassurance altogether and then (even more challenging)
say the opposite of what the client wants to hear. For example, if the client asks a family
member, “Do you think my heart racing is a sign of heart attack?” the family member
could say, “Yes, it very well might be a heart attack.”

Many information-seeking individuals with illness anxiety will report spending a lot of
time conducting online searches of symptoms in an attempt to reassure themselves that
they are not at risk. This should be eliminated early in therapy. You can set up some
structure as to how to limit the searching online. For example, if you have a client who is
spending two hours per day on the Internet checking and researching symptoms, it may
not be feasible right away to tell them to stop altogether. Therefore, work with the client
to add items to the hierarchy that include spending less than an hour per day research-
ing symptoms on the Internet, going one day without conducting any online searches of
symptoms, spending only thirty minutes four times a week researching symptoms, and so
on, until the problematic behavior has stopped.

Clients with information-seeking illness anxiety may repeatedly check themselves for
signs of illness. For example, clients with cardiac illness might check their blood pressure
or heart rate at home using a monitor, or simply check their pulse with their fingertips.
Those with cancer-related concerns might engage in repetitive body checking and scan-
ning for lumps, bumps, or discoloration of the skin. Clients with HIV fears may get tested
repeatedly and unnecessarily. Talk to your client about eliminating these behaviors.

In contrast, clients with the information-avoidant type of illness anxiety may distract
themselves from really thinking about their symptoms by trying to keep busy or by
changing the topic of conversation if it is anxiety-provoking. Ask the client to refrain from
distraction, stay engaged in the conversation, and pay attention to the symptoms rather
than avoiding them. Some clients may have asked other people in their lives to not talk
about certain anxiety-provoking topics; encourage the client to let people talk about
whatever they want to talk about without being afraid of upsetting the client.
Illness Anxiety Disorder 191

CONCLUSIONS
Illness anxiety disorder can be a debilitating condition. Individuals often present with
high levels of anxiety as well as avoidance or checking behaviors in an effort to alleviate
the intense anxiety about having a medical condition that could have gone undetected.
We have highlighted major categories of concerns that are frequently seen among those
with illness anxiety, including cardiac concerns, cancer, HIV/AIDS, degenerative neuro-
logical disorders, and a concern about going “crazy.” You can use these exposures as they
are written and can also individualize them to fit the needs of the specific concerns of
your client, which will lead to the most optimal outcomes.
In the next and last chapter, we will introduce you to ways in which you can help
both adults and children who have separation anxiety. We will provide many exposure
ideas for you to use with your client to target a fear of being separated from an attach-
ment figure.

CHAPTER RESOURCES

Example Imaginal Exposure Script—Cardiac Concerns

I have been feeling slight pains on the left side of my chest. My doctor has told me
that everything is fine and not to worry…it’s only anxiety. I’m not so sure and feel
that my doctors are incompetent and that something is terribly wrong. They tend to
think it is only in my head and I am just being dramatic. I try to stay calm. All of
a sudden, the pains in my chest worsen and I grab my chest and fall to the hard,
wooden floor. My mind is racing and I think, I knew I should have never listened
to my doctors. My breathing quickens and I begin to feel dizzy. Things seem unreal
around me. My phone is out of reach and there is no one around to save me. This
is it. I’m about to die. I should have never listened to my doctors.

Example Imaginal Exposure Script—Cancer

This is what my life has become. I am hooked up to machines and being fed poison to
fight the poison that has already made a home for itself in my body. This cancer has
consumed my entire life. I am either sitting in a doctor’s office, talking on the phone
with a doctor, reading about cancer, talking about it with friends and family, or trying
to comfort those around me who are most scared by my diagnosis. Having beautiful
hair is a thing of my past. I have watched it come out chunk by chunk and be littered
across my house before I made the painful decision to shave the rest of it off. While I
spend most of my days feeling ill, unable to eat much, and remembering the life I once
I had, I am most scared of what lies ahead. I am full of fear and anxiety. The doctors
say, “Take one day at a time,” but even that sounds incredibly overwhelming. I can’t
stand this anymore. I am no longer my own person and have so little dignity left.
192 The Big Book of Exposures

Example Imaginal Exposure Script—AIDS

For the past year I’ve had so many unexplained medical symptoms, such as weight
loss, fatigue, and these weird splotches on my skin. I have always avoided the doctor
because it causes me so much anxiety, but I finally decided to go get checked out at
the urging of my family. During the exam, my doctor tells me he recommends I get
tested for HIV/AIDS. Immediately I am filled with terror and flash back to all of the
times I could have come into contact with the virus. I agree to the testing but do so
reluctantly. My palms are sweaty and my heart is racing as I face into my fear and
pray that this will probably be fine in the end.
In the days to come, I wait and wait for my test results, constantly checking my
voicemail to hear from the doctor. No news. Eventually I think, No news must be
good news. As time goes by, I almost forget about the results until I pick up my cell
phone one afternoon. My doctor tells me, “I’m sorry. You have AIDS.” He starts to
tell me the next steps but I hear nothing. I am frozen in time. The room spins and I
cannot focus. How did I get this and who did I infect? I hear the doctor tell me how
advanced the disease is and how I don’t have much time left. I should have been
tested sooner.

Example Imaginal Exposure Script—Going Insane

I open my eyes and the room is unfamiliar. It is cold and dark and small. I start to
come to and realize I am in a padded cell. I can’t move my arms. I can’t move my feet.
I struggle to see what is holding me down, only to see metal clamps keeping my limbs
planted firmly to this bed. I start to call out, “Hello?” No one answers. I panic and
begin to yell, “Get me outta here!!!!” I struggle to get free but there is no hope. I hear
a voice talking to me, telling me that the government is who did this to me. I knew
they were bad. They’ve been after me all these years, watching me through my
window, following me to the grocery store, calling my phone pretending to me
telemarketers. I knew they were watching me and now here I am.
A man dressed in white enters the room with a tray of medications and a small
glass of water. I know they want me to swallow a tracking device masqueraded as a
pill so that they can watch all my moves. I refuse to open my mouth, but the man is
stronger than me and I have to take it. He tells me, “It’s okay; the medicine will help
you feel better and you will feel more like yourself. You’ve had a psychotic episode.”
I have flashes of my “old” self working, taking care of my family, and having fun in
my life. I vaguely remember how I slowly started to feel like things were “off” with me
and I started hearing sounds when no sounds were there. I feared losing my mind but
dismissed the thoughts. I should have trusted myself back then and looked for help
because this is my new home now.
 CHAPTER 11

Separation Anxiety Disorder

This chapter will cover the definition of separation anxiety disorder and how it manifests
differently in children and adults. We provide some important treatment considerations
and discuss how separation anxiety in children and adolescents may result in school
refusal. This chapter will include various types of exposures for children, adolescents,
and adults with the disorder.

WHAT IS SEPARATION ANXIETY DISORDER?

Nearly 7% of adults and adolescents have a lifetime history of separation anxiety disorder
(Kessler et al., 2012), a condition that is most commonly seen in children but which can
be present in adults as well. The DSM-5 (APA, 2013) outlines the criteria for separation
anxiety disorder as follows:

A. An excessive and developmentally inappropriate fear about separation from an

attachment figure, with at least three of the following symptoms:
1. Excessive distress about separating from home or attachment figures
2. Excessive worrying about losing attachment figures or about harm coming
to them
3. Excessive worrying about experiencing an event, such as getting lost, that
would result in separation from an attachment figure
4. Reluctance to go away from home, to school, or to other places due to fears
of separation from an attachment figure
5. Fear of being alone or without an attachment figure
6. Reluctance to sleep without being near an attachment figure
7. Nightmares about separation
8. Physical symptoms (e.g., headaches, stomachaches) in response to actual or
anticipated separation from an attachment figure

B. The fear and avoidance are persistent (e.g., four weeks in children, six months
in adults).
194 The Big Book of Exposures

C. The fear and avoidance cause significant distress or functional impairment.

D. The fear and avoidance cannot be better explained by another mental health
disorder, such as agoraphobia, psychotic disorders, or autism spectrum disorder.

Fear and Avoidance in Separation Anxiety Disorder

Individuals with separation anxiety disorder fear being separated from a major
attachment figure, such as a parent or spouse. Thus, daily activities such as going to
school or work can be frightening. Fears in separation anxiety disorder may be expressed
as somatic symptoms or as nightmares. The hallmark cognitive feature of separation
anxiety disorder is worrying about catastrophes. Specifically, clients with this disorder
may worry excessively about something bad happening to an attachment figure—for
example, that a parent will become ill, get injured, or die. They may also worry that
something will happen that will cause separation from the figure—for example, that they
will get lost or be kidnapped.
Children with separation anxiety disorder may refuse to attend school or other activ-
ities outside of the home or away from parents. Adults with separation anxiety disorder
may be unable to attend work or even leave the home without a trusted attachment
figure. Clients with separation anxiety may also have difficulty being home alone, or
going to sleep alone, without the attachment figure present.

Important Considerations in the Treatment of

Separation Anxiety Disorder
Some anxiety related to separation from a caregiver at a young age, such as in a
toddler, is very common and is part of a normal phase of development. However, as the
individual becomes older, it may be indicative of an anxiety disorder. It is important to
determine the developmental appropriateness of the fear and avoidance before diagnos-
ing separation anxiety disorder.
Note that there is a behavioral overlap with agoraphobia; in both conditions, the
person may be reluctant to go places, or be home alone, without a trusted other person.
The critical difference is that in agoraphobia, the individual primarily fears experiencing
panic-like symptoms or their consequences, whereas in separation anxiety disorder the
person primarily fears separation from the attachment figure. It is therefore critical to
assess the core fears for an accurate differential diagnosis. For a discussion of exposure for
agoraphobia, please see chapter 6.
Separation Anxiety Disorder 195

BEHAVIORAL TREATMENT FOR SEPARATION

ANXIETY DISORDER
We have divided this chapter into exposures for children and exposures for adults, as this
disorder may manifest differently in these two age groups. We have also included a
section specifically targeted for clients who refuse to go to school, although school refusal
is not exclusive to separation anxiety (that is, kids with a wide range of anxiety-related
disorders might refuse to attend school). If your client refuses to attend school, addressing
this will be a major component of the treatment, with the goal of helping the child or
adolescent return to school as soon as possible. We will provide exposure ideas for how
to help your younger client resume routine schooling.

Behavioral Treatment for Children and Adolescents

with Separation Anxiety Disorder
When conducting exposures with a child or adolescent who has separation anxiety,
keep in mind the appropriateness of exposures based on the developmental level of the
client. For example, it would not be appropriate to leave a seven-year-old child with sepa-
ration anxiety home alone for several hours with no supervision. Therefore, the expo-
sures listed below will need to be tailored to the client’s age.
We recommend that you refer to chapter 4, which focuses on how to help younger
clients with anxiety. This is often a good time to use rewards for the child’s brave behav-
ior when doing exposures.
196 The Big Book of Exposures

Exposures for Children and Adolescents

with Separation Anxiety

In-Office Exposures: CHILDREN AND ADOLESCENTS WITH SEPARATION

ANXIETY

• Create distance. Have your client practice being separated from his attachment
figure while in your office for a session. You may need to start with your office door
open and the attachment figure sitting in the hallway. You can then advance to shut-
ting the office door with the younger client knowing that his attachment figure is
directly outside the door. Slowly create more and more distance from the attach-
ment figure in each session to the point where the client’s attachment figure might
stay in the car for a session and will eventually drop the client off and run an
errand.

• Create an imaginal exposure script. Create a detailed story with the client about
his worst fears about separating from his parent, caregiver, or other attachment
figure. (See the imaginal exposure script at the end of this chapter.)

• Play a game. Play a game with your client in which you go back and forth coming
up with all the scary things that could be happening to the attachment figure at that
very moment while the client is in your office. See who can “win” the game by
coming up with most ideas (e.g., attachment figure getting struck by lightning,
getting into a car accident when going out for coffee while the child is in session,
having a heart attack in the waiting room).

• No goodbyes. Instruct the attachment figure to drive away from the session for a
few minutes without the child’s saying “Goodbye;” “I love you;” or anything else
comforting. You can later have the child work toward saying things such as “Don’t
drive safely” or “I hope you get into an accident” to the attachment figure before
they separate from each other.
Separation Anxiety Disorder 197

Out-of-Office Exposures: CHILDREN AND ADOLESCENTS WITH SEPARATION

ANXIETY

• Be on different floors of the home. Ask the child to spend time on the second floor
of the house while the attachment figure is on the first floor of the house or in the
basement. Slowly increase the time spent on different floors of the home.

• Take a walk or bike ride. Ask the child to take a walk or ride his bike away from
home for one minute and then slowly increase the amount of time spent away from
the home.

• Get a babysitter. Ask the attachment figure to go out for a short period of time
(e.g., thirty minutes) and have a babysitter stay home with the child. When this gets
easier for the child, the parents can go out for longer periods of time.

• Be separated for an undetermined amount of time. Set up an exposure in which

the attachment figure tells the child he or she is running an errand and doesn’t know
how long it will take. This is helpful in challenging the child to manage more ambigu-
ous situations in which he does not have all the details. You can tell the attachment
figure to make the exposure brief (ten to fifteen minutes), but the child will not have
this information.

• Go to a sleepover. Ask the child to make plans to go to a sleepover. To make the

exposure more challenging, you can assess what factors would make this exposure
more difficult, such as whether or not the child is staying over at a friend’s or family
member’s house or how far the child will be from home. Modify these variables as
appropriate to change the level of difficulty of the exposure.

• Attend a camp. Work toward having your client go to a day camp during the
summer or eventually a sleepaway camp, especially if it is something he might have
wanted to do if anxiety didn’t interfere with that desire.
198 The Big Book of Exposures

Safety Behaviors to Eliminate: CHILDREN AND ADOLESCENTS WITH

SEPARATION ANXIETY

Often children or adolescents will seek reassurance from the “safety person” (see
chapter 6) that he or she will be okay. Try to eliminate this reassurance. Eventually, the
attachment figure should be instructed to say things like “I don’t know if I will be okay,”
or “No, something bad may happen while I am out of the house.” The child should be
told when this safety behavior is going to be eliminated and when the attachment figure
is going to start saying the opposite of what the child (or child’s anxiety) wants to hear.

Children and adolescents may end up using applications on their cell phones to locate
where the attachment figure is at all times (through a GPS). First, limit the use of these
apps (e.g., starting with reduced checking time) and then work toward deleting the apps
altogether. If the child finds it too challenging to delete the app, the attachment figure
can turn off his or her GPS location so that the child can’t access it.

Ask the child to reduce clinginess or hanging on to the parent or other attachment figure.
Also work with your client to reduce the number of times he is calling or texting to check
in with the attachment figure, such as when home with a babysitter or in another location
away from the attachment figure.

Behavioral Treatment for School Refusal

School refusal, while not a DSM-5 diagnosis, can create significant distress for the
client, family members, and school personnel. School refusal is not only a consequence
of separation anxiety disorder but can also be related to panic, social anxiety, depression,
or other concerns. It is beyond the scope of this book to outline all of the treatment
interventions for school refusal, though behavioral interventions are often a major aspect
of treatment. We have included exposure ideas for helping the child or adolescent return
to school while you continue to work with him on the reasons for school avoidance, such
as separation anxiety disorder, social anxiety, or another anxiety-related disorder. Note
that most of the exposure exercises for school refusal are out-of-office exposures, as the
child must gradually take steps to be in school.
There are books devoted to in-depth protocols for the treatment of school refusal.
We have included the exposure component of the treatment here, but we note that other
interventions are often needed for a more thorough and complete treatment. School
refusal treatment should also involve parents, teachers, and staff at the school as well as
a specific reentry plan.
Separation Anxiety Disorder 199

Exposures for School Refusal

In-Office Exposures: SCHOOL REFUSAL

• Interoceptive exposures. For the child who refuses to go to school due to fears of
having panic-like sensations, practice doing interoceptive exposures to address
feared bodily sensations that occur—or that the child fears will occur—while at
school, such as dizziness or shortness of breath. As described in chapter 6, intero-
ceptive exposures can include strategies to:
• 
Induce feelings of heat flashes, such as wearing warm clothing
• 
Induce lightheadedness, such as hyperventilating or getting up quickly
• 
Induce shortness of breath, such as breathing through a straw
• 
Induce dizziness, such as spinning in a chair
• 
Increase heart rate, such as running in place
• 
Induce mild derealization, such as staring at lights or spinning circles online

• Role-plays for social anxiety. For the child who refuses to go to school because of
fears of interpersonal interactions, role-play these challenging interactions (with
confederates if possible), providing feedback as you go. You can find a long list of
these role-play exposures in chapter 7. Briefly, in-office exposures for socially
anxious children can include:
• 
Practicing giving class presentations or speaking up in class
• 
Practicing using a public restroom
• 
Practicing starting and maintaining conversations, including making small mis-
takes on purpose
• 
Getting comfortable with embarrassment by doing “silly” things in front of con-
federates or deliberately looking anxious in front of others

• Role-plays for returning to school. It may also be useful to give particular atten-
tion to role-playing conversations about the child’s (sometimes prolonged) absence
from school. When a child returns to school after an absence, it’s not unusual for
peers to ask where he has been. Children with school refusal often find this conver-
sation uncomfortable, thus leading to more avoidance. We often encourage a “little
white lie” here, in which the child explains that he had an illness or injury, and then
shifts the topic to ask his peers what he missed.
200 The Big Book of Exposures

Out-of-Office Exposures: SCHOOL REFUSAL

• Ride the school bus. If the child is used to having his attachment figure drive him to
school and engage in lengthy goodbyes, it may be helpful to work toward having
the child start taking the bus to school.

• Take a walk. Ask the younger client to go to the school during school hours but only
to walk around the building a few times without entering it.

• Eat in the cafeteria. If the child has not been to school, consider asking the child to
go to school only for lunchtime, which can be less stressful for the client but will help
him get back into the school building during school hours.

• Go to recess. Encourage the client to return to school only for recess time. Once the
child has demonstrated that he can stay at school for the entirety of recess, then
add on time that the child is in school before and after recess time.

Safety Behaviors to Eliminate: SCHOOL REFUSAL

Work with your client to reduce the number of times he is calling or texting to check in
with the attachment figure when at school.
Separation Anxiety Disorder 201

Behavioral Treatment for Adults with Separation Anxiety

Disorder
Though separation anxiety disorder is more commonly seen in children, it can
present in adults as well. As discussed above, a careful differential diagnosis is required
to distinguish separation anxiety disorder from agoraphobia, in which the client may feel
a need to have a trusted companion in situations in which escape would be difficult or in
which it would be difficult to get help.

Exposures for Adults with Separation Anxiety

In-Office Exposures: ADULTS WITH SEPARATION ANXIETY

• Create an imaginal exposure script. Create a detailed imaginal exposure script

with your client about his feared outcome when separated from a spouse, parent, or
other figure.

• Say scary phrases. Ask your client to repeat feared phrases such as “My husband
is going to die when coming home from work today.” Increase the difficulty of this
exposure by having the client say this phrase while looking at pictures of his spouse.

• Read an online article. Do an online search with your client to find articles describ-
ing situations that are similar to his fears, such as people whose spouses have been
killed in accidents, people who have been attacked or mugged, and so on.

• Watch online video clips. Find video clips online of individuals who were injured,
attacked, or died when alone. Watch these clips repeatedly with the client and
have the client repeat phrases such as “This could happen to me” or “This could
happen to my wife.”
202 The Big Book of Exposures

Out-of-Office Exposures: ADULTS WITH SEPARATION ANXIETY

• Create more distance. Ask your client to start increasing the time spent away from
his attachment figure. For example, if the client will not run errands without the
attachment figure, have him start planning small trips to the bank, and then the
grocery store, and then plan other activities that increase the amount of time sepa-
rated from the person on purpose (e.g., not just due to being at work).

Safety Behaviors to Eliminate: ADULTS WITH SEPARATION ANXIETY

Adults with separation anxiety may seek reassurance from the attachment figure that he
or she will be okay. Encourage the client to discontinue this behavior, and coach the
attachment figure to decline to answer the questions should they come up.

Remove applications on the client’s cell phone that enable the client to locate where the
attachment figure is at all times (through a GPS). Also work with your client to reduce the
number of times he is calling or texting to check in with the attachment figure.

CONCLUSIONS
Separation anxiety can be debilitating and can negatively interfere with the lives of both
children and adults. Separation anxiety in children and adolescents can result in a refusal
to attend school. However, it is important to note that school refusal can be related to
other psychological disorders as well, such as depression or social anxiety. Individuals
with separation anxiety may also have difficulty being home alone or separated in any
way from the attachment figure. The exposure ideas included in this chapter will be
helpful in allowing individuals with separation anxiety to face their fears and resume
normal activity.
Separation Anxiety Disorder 203

CHAPTER RESOURCES
Reminder: These resources are also available to download and print from http://www.
newharbinger.com/43737.

Example Imaginal Exposure Script—Separation Anxiety Disorder

I am getting ready for my sleepover at a friend’s house and I start getting a pit in the
bottom of my stomach. My heart starts racing and I worry about being away from my
parents. I hate sleeping away from home and worry something really bad could
happen to my mom and dad. My parents tell me I have to go. I get in the car and start
to cry. My mind starts creating scary images of my parents getting sick, getting into a
car accident, or even dying. Something bad will happen if I am not with them. I make
it to the sleepover and have fun until it’s time to go to bed. I lie awake waiting for
something bad to happen and try to count down the minutes until I am home. My
anxiety then gets worse and worse and I feel like I can barely breathe. I call my mom’s
cell phone and there is no answer. I call my dad’s cell phone next and there is no
answer. I then frantically start dialing our house phone to see if either of them will
pick up the phone. No answer. I see police lights in the distance lighting up the dark
night. They are coming closer and closer to where I am staying. I am about to receive
some really bad news.

Let’s Separate Game!

Materials:
• Prewritten or blank template provided below
• Pen or pencil
• Scissors

Rules: Cut up the prewritten template provided below, and divide the pieces of paper
into three piles: (1) amount of time the attachment figure will spend separated from the
child, (2) where the attachment figure will go, and (3) what the therapist and child will
say repeatedly in the office during the exposure. In addition to the prewritten template,
we have included a blank template on which you can customize the times, places, and
things to say to suit the needs of the client. For each round, the child will blindly choose
a piece of paper from each pile, thus creating the framework for the exposure. Set the
timer and get separating! Remember to use rewards as needed.

Note: If you are using the prewritten template, fill in the blanks in the third column with
your client at the beginning the exercise.
204 The Big Book of Exposures

Prewritten template

1 minute Outside of the therapy office My          is going

door to be hurt or killed.
2 minutes Outside the therapy building I’ll never see         
again.
5 minutes In the car          will never
come back to get me.
10 minutes Driving or walking down the Bad things are happening
street to         .
15 minutes Caregiver’s choice of where to Say aloud my worst fear
go

Blank template
 Acknowledgments

While I (KSS) had the idea to write this book a few years ago, it wasn’t ever something I
believed to be possible; and it wouldn’t have been possible without the support of many
people. A big thank you to all my graduate school (and beyond) mentors who encouraged
and inspired me to think outside the box with exposures and get creative with the treat-
ment of my patients. A special thank you to my parents, Paul and Darlene, who inspired
my love of reading, learning, and helping others, all of which led to the development of
this book. I would also like to thank my husband, Mike, for being incredibly supportive
during this journey.
David and I would like to extend our thanks to all those who contributed ideas to
our book, including Blaise Worden, Hannah Levy, Kimberly Stevens, and Carolyn
Davies. Most of all, we would like to acknowledge our entire team at New Harbinger with
a special thanks to our acquisition editor, Tesilya Hanauer, for seeing something special
in our book and guiding us through every step of this process.
None of this would be possible without our clients, who have helped us get our cre-
ativity flowing to find new ways to help them through exposure. They have been the
ones to tell us what has worked and what hasn’t and through that have helped us refine
our exposure skills. Thank you!
 References

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Alpers, G. W., & Sell, R. (2008). And yet they correlate: Psychophysiological activation predicts self-
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1109. doi:10.1016/j.janxdis.2007.11.009
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.,
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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC: Author.
Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M. G. (2010). Does habituation
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Smits, J. A., Telch, M. J., & Randall, P. K. (2002). An examination of the decline in fear and disgust
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Kristen S. Springer, PhD, is a licensed clinical psychologist in Massachusetts with a
private practice in the greater Boston, MA, area. She earned her doctoral degree from
the University of Florida, and completed her postdoctoral clinical and research training
at the Anxiety Disorders Center and the Center for Cognitive Behavioral Therapy at the
Hartford Hospital Institute of Living in Hartford, CT. She continued working at the
Anxiety Disorders Center as a staff psychologist before opening her private practice
where she specializes in the assessment and treatment of obsessive-compulsive disorder
(OCD) and anxiety disorders in adolescents and adults. Springer has authored several
book chapters and scientific journal articles in the fields of anxiety, hoarding, OCD, and
chronic pain. You can learn more about her at www.massanxietytreatment.com.

David F. Tolin, PhD, is founder and director of the Anxiety Disorders Center and the
Center for Cognitive Behavioral Therapy at the Hartford Hospital Institute of Living in
Hartford, CT. He is adjunct professor of psychiatry at Yale University School of Medicine,
and maintains a private practice in the greater Hartford area. Tolin has authored more
than 150 scientific journal articles, as well as the books, Face Your Fears and Doing CBT.
 Index

A 183–192; OCD, 139–166; panic

disorder, 105–119; separation anxiety
about this book, 1–2
disorder, 193–204; social anxiety
accident-related fears, 175–176; imaginal
disorder, 121–138; specific phobias,
exposure script for, 181; in-office
69–103
exposures for, 175; out-of-office
anxious appearance, fear of, 135–136;
exposures for, 176; safety behaviors
in-office exposures for, 135; out-of-
related to, 176
office exposures for, 135; safety
accommodations, family, 56–58, 64
behaviors related to, 136
action stage of change, 23, 24–25
applied tension, 74
acute stress disorder (ASD), 167–170;
argument avoidance, 23
diagnosis of, 167–168; fear and
art of doing nothing, 42
avoidance in, 169; overview of PTSD
ASD. See acute stress disorder
and, 167, 180; treatment
assault-related fears: physical assault,
considerations, 170. See also
171–172; sexual assault, 173–174
posttraumatic stress disorder
assessment: of obsessive-compulsive
adolescents. See children and adolescents
disorder, 141; SUDS used for ongoing,
agoraphobia: co-occurrence with panic
38–39
disorder, 105; DSM-5 criteria for, 107;
attentional bias, 6
fear and avoidance in, 108–109;
avoidance: anxiety-related, 7–8; in ASD/
imaginal exposures for, 116, 119; in
PTSD, 169; fear impacted by, 8; in
vivo exposures for, 114–115;
illness anxiety disorder, 184; in
interoceptive exposures for, 110–113;
obsessive-compulsive disorder, 140–141;
safety person for, 109–110; specific
in panic disorder and agoraphobia,
phobias vs., 109. See also panic disorder
108–109; in separation anxiety
animal phobias, 70, 80–85; fear of bugs,
disorder, 194; in social anxiety
84–85; fear of dogs, 82–83; fear of
disorder, 122; in specific phobias,
snakes, 80–81; safety behaviors related
70–71; toxic role of, 17–19
to, 85
anxiety: behavior and, 7–8; cognition
and, 6; cost of, 5–6; creature drawing,
B
61; exposure therapy and, 10; naming, behavior: anxiety and, 7–8;
60; physiology of, 6, 21, 32; psychoeducation about, 16, 17; safety,
psychoeducation about, 15–17. See also 7–8, 41, 48
fear between-session habituation, 40
anxiety disorders, 5; ASD and PTSD, blood-injection-injury (BII) phobias, 70,
167–182; illness anxiety disorder, 74–79; imaginal exposure scripts for,
218 The Big Book of Exposures

99; in-office exposures for, 75–76, 78; pitching exposure to, 15; stages of
out-of-office exposures for, 77, 79; change in, 23–25
safety behaviors related to, 79 coaching children, 55
bodily sensations, exposure to, 32–35 cognition, anxiety and, 6
bribes vs. rewards, 61 cognitive behavioral therapy (CBT), 1
bugs, fear of, 84–85; imaginal exposure cognitive distortions, 6
script for, 101; in-office exposures for, collaborative empiricism, 25
84, 103; out-of-office exposures for, 85 combat-related fears, 177–178; imaginal
exposure script for, 182; in-office
C exposures for, 177; out-of-office
cancer-related concerns, 185, 191 exposures for, 178; safety behaviors
cardiac concerns, 185, 191 related to, 178
catastrophizing, 6 complex PTSD, 170
CBT triangle, 16 compulsions, 139, 140. See also obsessive-
change, stages of, 23–25 compulsive disorder
change talk, 24 conditional safety, 12, 41, 48
checking-based OCD, 160–161; imaginal conditioned stimulus (CS), 42–43
exposure script for, 166; in-office contamination-related OCD, 142–146;
exposures for, 160, 161; out-of-office in-office exposures for, 143–144;
exposures for, 160, 161; safety behaviors out-of-office exposures for, 145; safety
related to, 161 behaviors related to, 146
children and adolescents, 11, 53–66; contemplation stage of change, 23, 24
OCD assessment and treatment in, coping: during exposure, 41–42; skill
141; parent-based interventions with, training, 11, 41
54–59; playing games with, 59–60, counterconditioning, 41
65–66; psychoeducation on exposure
therapy with, 53–54; reducing family D
accommodations given to, 56–58, 64; deepened extinction, 46–47
refusal of treatment by, 59; rewards degenerative neurological disorders, 185
used with, 61–62; separation anxiety dentists, fear of, 78–79; imaginal exposure
disorder in, 193, 194, 195–200; script for, 99; in-office exposures for,
strategies for working with, 59–61 78; out-of-office exposures for, 79;
choking, fear of, 96–97; imaginal exposure safety behaviors related to, 79
script for, 102; in-office exposures for, Diagnostic and Statistical Manual of Mental
96; out-of-office exposures for, 97; Disorders (5th ed.; DSM-5), 1;
safety behaviors related to, 97 agoraphobia criteria, 107; illness
claustrophobia, 41, 42, 91, 114 anxiety disorder criteria, 183; OCD
clients: child and adolescent, 53–66; criteria, 139–140; panic disorder
collaborating with, 25; establishing criteria, 105–106; separation anxiety
rapport with, 22; explaining exposure criteria, 193–194; social anxiety
to, 19–20; modeling exposure with, 25; disorder criteria, 121–122; specific
phobia criteria, 69
Index  219

disaster-related fears, 179–180; in-office exposures (specific): for animal phobias,

exposures for, 179; out-of-office 80–85; for blood-injection-injury
exposures for, 179; safety behaviors phobias, 75–79; for illness anxiety
related to, 180 disorder, 187–189; for natural
discrepancy, reflecting to clients, 23–24 environment phobias, 72–73; for
disgust sensitivity, 70 obsessive-compulsive disorder, 143–161;
distraction, limiting, 44–45 for panic disorder and agoraphobia,
distress tolerance, 42 111–116; for post-traumatic stress
dogs, fear of, 82–83; imaginal exposure disorder, 171–180; for separation
script for, 100; in-office exposures for, anxiety disorder, 196–202; for
82; out-of-office exposures for, 83 situational phobias, 86–92; for social
anxiety disorder, 125–136; for vomiting
E and choking phobias, 93–97. See also
educating clients. See psychoeducation in-office exposures; out-of-office
embarrassment, fear of, 132–136; anxious exposures
appearance and, 135–136; in-office external stimuli avoidance, 7
exposures for, 132, 135; out-of-office extinction: deepened, 46–47; occasional
exposures for, 133, 135; safety behaviors reinforced, 49
related to, 134, 136
expectancy violation, 43–44 F
exposophobia: interoceptive exposures fainting response, 74
and, 34, 110; myths related to, 10–11 family accommodations, 56–58, 64
exposure: imaginal, 29–31; in vivo, 9, fear: actions antagonistic to, 45–46;
27–29; interoceptive, 9, 32–35; activation vs. deactivation of, 42; in
modeling, 25; to thoughts, 31–32; ASD/PTSD, 169; avoidance related to,
virtual reality, 35–36 8; discussing with clients, 20–21;
exposure hierarchy, 36–39; creating with guiding exposures based on, 39–40; in
SUDS, 36–38; form for working with, illness anxiety disorder, 184; in
51; ongoing assessment and, 38–39 obsessive-compulsive disorder, 140; in
exposure therapy: coping during, 41–42; panic disorder and agoraphobia,
emphasizing effectiveness of, 21–22; 108–109; in separation anxiety
explaining to clients, 19–20; disorder, 194; in social anxiety
habituation in, 40; hierarchy of disorder, 122. See also anxiety; specific
exposures in, 36–39; inhibitory phobias
learning used in, 42–50; length of fear conditioning, 8
exposures in, 40; managing fear level fear extinction, 8
in, 39–40; pitching to clients, 15; feelings, psychoeducation on, 15–16, 17
psychoeducation about, 15–22; reasons flying, fear of, 89–90; imaginal exposure
for using, 8–10; types of exposures used script for, 101; in-office exposures for,
in, 27–36; with younger clients, 53–66 89; out-of-office exposures for, 90;
exposure with response prevention, 9 safety behaviors related to, 90
220 The Big Book of Exposures

G panic disorder and agoraphobia,

114–115
games, psychoeducational, 59–60, 65–66
inhibitory learning, 8, 42–50; context
changes and, 50; deepened extinction
H and, 46–47; distraction and, 44–45;
habituation, 40 expectancy violation and, 43–44;
harm-based OCD, 152–157; fear of fear-antagonistic actions and, 45–46;
harming others in, 155–157; imaginal occasional reinforced extinction and,
exposure scripts for, 165; in-office 49; safety behaviors and, 48
exposures for, 153, 155; out-of-office injections, fear of, 75–77
exposures for, 154, 156; safety in-office exposures: for animal phobias,
behaviors related to, 157; self-harm 80, 82, 84; for blood-injection-injury
obsessions in, 153–154; suicidal or phobias, 75–76, 78; for checking-based
homicidal ideation vs., 152 OCD, 160, 161; for contamination-
heights, fear of, 86–88; in-office exposures related OCD, 143–144; for harm-based
for, 86; out-of-office exposures for, 87; OCD, 153, 155; for illness anxiety
safety behaviors related to, 88 disorder, 187–188; for natural
hierarchy, exposure, 36–38 environment phobias, 72; for ordering/
HIV/AIDS-related concerns, 185, 192 arranging/”not just right”/symmetry
homicidal ideation, 152 OCD, 158; for panic disorder and
hypochondriasis, 183 agoraphobia, 111–112, 114, 116; for
pedophilia-themed OCD, 150; for
I posttraumatic fears, 171, 173, 175, 177;
illness anxiety disorder, 183–192; DSM-5 for scrupulosity-related OCD, 147; for
criteria for, 183; fear and avoidance in, separation anxiety disorder, 196, 199,
184; imaginal exposure scripts for, 201; for situational phobias, 86, 89, 91;
191–192; in-office exposures for, for social anxiety disorder, 125–126,
187–188; interoceptive exposures for, 128, 131, 132, 135; for vomiting and
187, 188; out-of-office exposures for, choking phobias, 93–94, 96. See also
188–189; safety behaviors related to, out-of-office exposures
190; specific health concerns in, 185; insanity-related concerns, 185, 192
treatment considerations, 184 insects. See bugs, fear of
imaginal exposures, 29–31; examples of, internal stimuli avoidance, 7
29–30; guidelines for setting up, 30–31; interoceptive exposures, 9, 32–35;
for illness anxiety disorder, 191–192; for examples of, 32–33; form for working
OCD, 165–166; for panic and with, 52; guidelines for setting up,
agoraphobia, 116, 119; for PTSD, 33–35; for illness anxiety disorder, 187,
181–182; for separation anxiety 188; for panic disorder and
disorder, 203; for social anxiety, 137; agoraphobia, 110–113
for specific phobias, 98–102
in vivo exposures, 9, 27–29; examples of, J
28; guidelines for setting up, 28–29; for jelly bean game, 93, 102
Index  221

L exposures for, 159; safety behaviors

related to, 159
learning, inhibitory, 8, 42–50
out-of-office exposures: for animal
Let’s Separate Game, 203–204
phobias, 81, 83, 85; for blood-injection-
injury phobias, 77, 79; for checking-
M based OCD, 160, 161; for
maintenance stage of change, 23, 24–25 contamination-related OCD, 145; for
Mandela, Nelson, 1 harm-based OCD, 154, 156; for illness
medical clearance form, 118 anxiety disorder, 188–189; for natural
medications, short-acting, 41–42 environment phobias, 72; for ordering/
mental health-related concerns, 185 arranging/”not just right”/symmetry
modeling exposures, 25 OCD, 159; for panic disorder and
motivational interviewing (MI), 23–25 agoraphobia, 113, 115, 116; for
myths, exposophobia, 10–11 pedophilia-themed OCD, 151; for
posttraumatic fears, 172, 174, 176, 178;
N for scrupulosity-related OCD, 148; for
naming anxieties, 60 separation anxiety disorder, 197, 200,
natural environment phobias, 70, 71–73; 202; for situational phobias, 87, 90, 92;
in-office exposures for, 72; out-of-office for social anxiety disorder, 127, 129,
exposures for, 73; safety behaviors 131, 133, 135; for vomiting and choking
related to, 73 phobias, 95, 97; for younger clients, 61.
“normal” human behaviors, 12 See also in-office exposures
not just right experiences (NJREs), 158
P
O PANDAS or PANS disorder, 141
obsessions, 139, 140 panic attacks, 106
obsessive-compulsive disorder (OCD), 9, panic disorder, 9, 105–119; DSM-5 criteria
139–166; assessment and treatment for, 105–106; fear and avoidance in,
considerations, 141; checking-based, 108–109; imaginal exposures for, 116,
160–161; contamination-related, 119; in vivo exposures for, 114–115;
142–146; DSM-5 criteria for, 139–140; interoceptive exposures for, 110–113;
fear and avoidance in, 140–141; medical clearance form for, 118;
harm-based, 152–157; imaginal nondangerous nature of, 106–107;
exposure scripts for, 165–166; ordering/ panic attacks vs., 106; safety person for,
arranging/”not just right”/symmetry, 109–110; treatment considerations, 109
158–159; pedophilia-themed, 149–151; parent-based interventions, 54–59;
scrupulosity-related, 146–148; spirit prompting, coaching, and praising in,
board game for, 163–164 55; reducing family accommodations
occasional reinforced extinction, 49 in, 56–58, 64; refusal of treatment and,
ordering/arranging/”not just right”/ 59
symmetry OCD, 158–159; in-office Pascal, Blaise, 24
exposures for, 158; out-of-office
222 The Big Book of Exposures

pedophilia-themed OCD, 149–151; PTSD. See posttraumatic stress disorder

in-office exposures for, 150; out-of- public restroom fears, 128–129; in-office
office exposures for, 151; pedophilia exposures for, 128; out-of-office
differentiated from, 149–150; safety exposures for, 129; safety behaviors
behaviors related to, 151 related to, 129
performance-related fears, 123–127;
imaginal exposure script for, 137; R
in-office exposures for, 125–126, 128; rapport, establishing, 22
out-of-office exposures for, 127, 129; reassurance-giving, 56–58
public restroom use as, 128–129; safety relaxation exercises, 41
behaviors related to, 127, 129 religion, scrupulosity-related OCD and,
phobias. See specific phobias 146–147
physical assault-related fears, 171–172; rereading/rewriting OCD, 161
imaginal exposure script for, 181; resistance, rolling with, 23
in-office exposures for, 171; out-of- rewards, using with children, 61–62
office exposures for, 172; safety risk, consideration on, 13
behaviors related to, 172
physiology of anxiety, 6, 21, 32 S
posttraumatic stress disorder (PTSD),
safety behaviors, 7–8, 41, 48; animal
10–11, 167–182; accident-related fears
phobias and, 85; blood-injection-injury
in, 175–176; combat-related fears in,
phobias and, 79; checking-based OCD
177–178; diagnosis of, 167, 168–169;
and, 161; contamination-related OCD
disaster-related fears in, 179–180; fear
and, 146; harm-based OCD and, 157;
and avoidance in, 169; imaginal
illness anxiety disorder and, 190;
exposure scripts for, 181–182; overview
natural environment phobias and, 73;
of ASD and, 167, 180; physical assault-
ordering/arranging/”not just right”/
related fears in, 171–172; sexual
symmetry OCD and, 159; panic
assault-related fears in, 173–174;
disorder and agoraphobia and, 113,
treatment considerations, 170
115, 116; pedophilia-themed OCD and,
praising children, 55
151; posttraumatic fears and, 172, 174,
precontemplation stage of change, 23–24
176, 178; scrupulosity-related OCD
probability overestimation, 6
and, 148; separation anxiety disorder
prompting children, 55
and, 198, 200, 202; situational phobias
pros and cons exercise, 24
and, 88, 90, 92; social anxiety disorder
psychoeducation, 15–22; with children
and, 127, 129, 131, 134, 136; vomiting
and adolescents, 53–54; emphasizing
and choking phobias and, 95, 97
exposure’s effectiveness, 21–22;
safety person, 109–110
explaining how exposure works, 19–20;
safety signals, 25
games to help kids learn, 59–60,
school refusal, 198–200; in-office
65–66; having a conversation about
exposures for, 199; out-of-office
fear, 20–21; making avoidance the
exposures for, 200; safety behaviors
enemy, 17–19; providing a model of
related to, 200
anxiety, 15–17
Index  223

scrupulosity-related OCD, 146–148; exposures for, 131; safety behaviors

in-office exposures for, 147; out-of- related to, 131
office exposures for, 148; safety social skills training, 122
behaviors related to, 148 SPACE Program, 59
self-harm obsessions, 141, 153–154, 165 specific phobias, 9, 69–103; agoraphobia
separation anxiety disorder, 193–204; in vs., 109; animal phobias, 80–85;
adults, 194, 201–202; in children and anxiety disorders and, 71; behavioral
adolescents, 194, 195–200; DSM-5 treatments for, 71–97; blood-injection-
criteria for, 193–194; fear and injury phobias, 70, 74–79; DSM-5
avoidance in, 194; imaginal exposure criteria for, 69; fear and avoidance in,
script for, 203; in-office exposures for, 70–71; imaginal exposure scripts for,
196, 199, 201; Let’s Separate Game for, 98–102; natural environment phobias,
203–204; out-of-office exposures for, 70, 71–73; situational phobias, 86–92;
197, 200, 202; safety behaviors related types or categories of, 70; vomiting and
to, 198, 200, 202; school refusal as type choking phobias, 93–97
of, 198–200; treatment considerations, spirit board game, 163–164
194 storm phobias: exposures for treating,
sexual assault-related fears, 173–174; 72–73; imaginal exposure script for, 98;
in-office exposures for, 173; out-of- safety behaviors related to, 73
office exposures for, 174; safety subjective units of distress scale (SUDS),
behaviors related to, 174 36–39; creating exposure hierarchy
short-acting medications, 41–42 using, 36–38; ongoing assessment
situational phobias, 70, 86–92; fear of using, 38–39
flying, 89–90; fear of heights, 86–88; substance abuse: exposure therapy and,
fear of tight spaces, 91–92; safety 10; PTSD and, 174, 178, 180
behaviors related to, 88, 90, 92 SUDS. See subjective units of distress
small-talk game, 138 scale
snakes, fear of, 80–81; imaginal exposure suicidal ideation, 152
script for, 100; in-office exposures for, surgery, fear of, 76
80; out-of-office exposures for, 81 systematic desensitization, 41
social anxiety disorder, 121–138; DSM-5
criteria for, 121–122; embarrassment T
fears in, 132–136; fear and avoidance thoughts: exposure to, 31–32;
in, 122; imaginal exposure script for, psychoeducation about, 15–16
137; performance-related fears in, tight spaces, fear of, 91–92; in-office
123–127; public restroom fears in, exposures for, 91; out-of-office
128–129; small-talk game for, 138; exposures for, 92; safety behaviors
social situation fears in, 130–131; related to, 92
treatment considerations, 122–123 trauma-related disorders. See acute stress
social phobia, 9 disorder; posttraumatic stress disorder
social situation fears, 130–131; in-office
exposures for, 130; out-of-office
224 The Big Book of Exposures

U W
unconditional safety, 12, 41, 48 within-session habituation, 40
unconditioned stimulus (US), 42–43 World Health Organization, 74

V Y
vasovagal response, 74 younger clients. See children and
virtual reality exposure therapy (VRET), adolescents
35–36; examples of, 35; guidelines for
setting up, 35–36
vomit/vomiting, fear of, 93–95; in-office
exposures for, 93–94; out-of-office
exposures for, 95; safety behaviors
related to, 95
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HELPING YOUR SHY & EXPOSURE THERAPY FOR THE OCD WORKBOOK,
SOCIALLY ANXIOUS CLIENT TREATING ANXIETY IN THIRD EDITION
A Social Fitness Training Protocol CHILDREN & ADOLESCENTS Your Guide to Breaking Free from
Using CBT A Comprehensive Guide Obsessive-Compulsive Disorder
978-1608829613 / US $49.95 978-1-62629225 / US $69.95 978-1572249219 / US $25.95

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 PSYCHOLOGY
For the treatment of

the
clients coping with anxiety,
Hundreds of innovative exposures for panic, phobias, OCD,

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PTSD & more
treating anxiety & related disorders

I n cognitive behavioral therapy (CBT), exposures are the gold standard for

treating anxiety and related disorders, including obsessive-compulsive
disorder (OCD), panic, and phobias. But if you’re like many clinicians, you’ve
likely encountered clients who are fearful or reluctant to try exposure therapy the
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in session. As a result, you may shy away from doing exposures for fear of
worsening your client’s anxiety or rupturing the client/therapist rapport.
So, how can you move past “exposure phobia” to ensure the most effective
treatment available?

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The Big Book of Exposures offers hundreds of innovative and easy-to-

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implement exposure exercises you can use in any setting and adapt to your

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clients’ unique needs. You’ll also find a comprehensive overview of exposure
therapy; a rationale for its use in treating anxiety; troubleshooting tips for

EXPOSURES
dealing with common roadblocks such as avoidance; and techniques for
helping clients stay motivated in session. With this essential resource, you’ll
learn to create engaging and enjoyable exposure exercises to improve
treatment outcomes and help your clients live better lives.

“A cornucopia of creative and effective exposure strategies for

a range of anxiety disorders…. If you’re in search of thoughtful
guidance on designing and implementing exposures,
add this book to your bookshelf.” Innovative, Creative & Effective CBT-Based Exposures
—Michael A. Tompkins, PhD, ABPP, author of Anxiety and Avoidance
for Treating Anxiety-Related Disorders
KRISTEN S. SPRINGER, PhD, is a licensed clinical psychologist with a private
practice in the greater Boston, MA, area, where she specializes in the assessment
and treatment of obsessive-compulsive disorder (OCD) and anxiety disorders in
Springer | Tolin
adolescents and adults.
Kristen S. Springer, PhD
DAVID F. TOLIN, PhD, is founder and director of the Anxiety Disorders Center
and the Center for Cognitive Behavioral Therapy at the Hartford Hospital Institute of David F. Tolin, PhD
Living in Hartford, CT. He is adjunct professor of psychiatry at Yale University School
of Medicine and maintains a private practice.

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