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(p. 137) Imaginal and Interoceptive Exposure Case Examples 

(p. 137) Imaginal and Interoceptive Exposure Case Examples
(p. 137) Imaginal and Interoceptive Exposure Case Examples

Stephen P. H. Whiteside

, Thomas H. Ollendick

, and Bridget K. Biggs

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date: 03 April 2020

In Chapter 7, we presented three cases demonstrating how to implement in vivo exposures. In addition to illustrating details of application, the cases also explored the broader issues of conducting exposures to situations in which one’s fears come true, breaking down exposures into small steps, and incorporating parents. In Chapter 8, we continue our case presentations with a focus on the less commonly used and less intuitive methods of imaginal and interoceptive exposure. We follow the same format as that used in Chapter 7 for presenting cases illustrating exposure application with obsessions and compulsions, general anxiety and worry, as well as panic. As before, we end each case example with discussion of broader concepts related to implementing exposure in clinical practice.

Case Examples: Imaginal Exposure

Obsessions and Compulsions


Peter was a 15-year-old 10th grader who presented with his mother for treatment of what the family referred to as constant anxiety. They described him as frequently worrying about harming himself or others. These worries were quite distressing to the patient and his parents because they were quite out of character for Peter, who was generally a kind and responsible teenager. His parents expressed concern that he was unable to be rational about these thoughts or accept their logical reassurances that his fears were unfounded. During the past few months, Peter reportedly had been isolating himself from friends and family, preferring to stay in his room alone watching videos or listening to music. More recently, his parents were alarmed when he stated that he wished he were not alive. Peter stated that he worried that he would hurt, specifically stab, himself or family members with a knife or scissors. His mother confirmed that he would often ask if she thought he would stab himself or his siblings and had gotten very (p. 138) upset one day because he thought it was dangerous and unnecessary to have so many knives in the house. When asked what other worry thoughts he had, Peter acknowledged there were others but stated he did not know what they were or how to describe them.

The family described Peter’s distressing thoughts as having been problematic for the past 3 months but present to a lesser degree for an additional 3 months before that. His mother reported that throughout the years, Peter had experienced anxiety periodically, including episodes of excessive handwashing and worry about school performance. However, these previous bouts had not been impairing, and they had been resolved without intervention beyond parental reassurance and limit setting. The current symptoms had not resolved with a similar approach and instead appeared to be worsening. Peter described his worries as most upsetting when he was with his friends or family and not occupied by a specific activity. This had led him to avoid being in close proximity to his two younger siblings and to not attend a recent family gathering at which there were additional younger cousins. He stated that he generally felt better at school and other times when he could distract himself from his thoughts by focusing on a task, such as academic work or physical activity. In addition to avoidance, his mother reported that he frequently asked for reassurance, such as whether she thought he would hurt someone, whether any of the knives were missing, or whether his siblings were okay. She described these questions as seeming to occur incessantly at times and being quite stressful for her and her husband. When they would attempt not to answer his worrisome questions, Peter would be insistent, at times crying or becoming angry, until they answered. In response to direct questions from the therapist, Peter suggested that he had some neutralizing thoughts and actions that he engaged in to relieve his distress, but he was vague regarding their nature and maintained that avoidance and talking to his parents were his primary means of coping.

Earlier in the current episode of heightened anxiety, the family had consulted with his pediatrician, who had referred him to a therapist. The therapist had diagnosed his symptoms as obsessive–compulsive disorder (OCD), and Peter attended a handful of appointments. The family described the previous therapist as working primarily with Peter alone, although his mother was included at the beginning and end of each appointment to discuss progress. Peter reported that the therapist instructed him in a number of coping strategies that included breathing exercises, focusing on positive images, and bossing-back OCD thoughts. The therapist had also encouraged Peter to stop avoiding knives and discussed doing exposures to sharp objects later in treatment. Peter stated that he liked his therapist, but the family and the therapist were concerned that he was not making progress. Subsequently, they sought care at the specialty clinic.


Based on the information gathered during the initial evaluation, the current therapist determined that a diagnosis of OCD indeed best described Peter’s symptoms. The family readily understood the discussion of OCD as consisting (p. 139) of intrusive thoughts that provoke anxiety or distress (obsessions), efforts to relieve this distress through repeated actions (compulsions), and that because these symptoms interfered with daily life, they qualified as a disorder. The therapist then introduced exposure and response prevention (ERP) as the most appropriate treatment. He explained that Peter would need to do activities and think thoughts that made him uncomfortable, without avoiding or asking for reassurance, until (1) he learned that what he was afraid of was unlikely to happen and (2) he could handle his distress until it decreased naturally. The therapist also explained that Peter’s mother (or both parents) would be involved in each of the sessions, learning how to coach him through exposures to help him be successful between sessions and after therapy ended.

When searching online for treatment options, Peter’s mother had learned about ERP and was in agreement with the treatment plan. She also appreciated the opportunity to be thoroughly involved in his care and to learn how to respond differently when he sought reassurance. Peter, on the other hand, was skeptical. He reasoned that he was already experiencing these thoughts frequently, sometimes constantly, and he did not understand how exposure therapy would be different. He also expressed reluctance to work closely with his parents on exposures, which appeared to be partly an age-appropriate desire for independence and partly discomfort revealing the content of some of his thoughts. The therapist responded that these concerns were valid, common, and showed that Peter was listening, understanding, and appropriately evaluating the information. The therapist explained that one of the primary differences between experiencing upsetting thoughts in daily life and therapeutic exposures is what happens to make one feel better. Specifically, he explained that in daily life, people typically do not feel better until they escape the thought by distraction or avoidance, so they never learn the thought is not dangerous. In therapy, he continued, they set up controlled experiments in which people focus on the thought long enough to feel better without avoiding. This teaches them that the thought itself is not dangerous. The therapist also added that the ultimate goal was for Peter to be able to handle his thoughts on his own, and if he required less parent involvement than other kids, that would be fine. Peter remained ambivalent but indicated he was willing to give it a try.

During the first therapy session following the initial assessment, the therapist introduced the anxiety/OCD cycle to Peter and his mother together and worked with them to apply it to Peter’s symptoms. Peter’s intrusive thoughts of harming himself or others, as well as other yet undisclosed thoughts, were identified as the primary precipitating stimuli that set off his OCD symptoms. Objects such as knives and situations such as being alone with a younger sibling or his cousins were also identified as stimuli that set off his anxiety by provoking the intrusive thoughts. Next, Peter was able to identify a number of expectations or beliefs that made his unwanted thoughts distressing. First, Peter believed that the presence of these thoughts signaled that something bad was going to happen. Primarily, he believed that having the thought meant he was likely to do the action, perhaps because his thoughts would overwhelm him, making him likely to harm himself (p. 140) or his family. In addition, he believed that having these thoughts meant he must want to do the action, and so there must be something wrong with him or he is a bad person. As a result of these expectations and beliefs, Peter not only felt scared and nervous about causing harm but also felt guilty and as if he really was a bad person.

Peter and his mother readily identified his withdrawal as well as his efforts to distract himself with activities and electronics as avoidance. Although perhaps not as problematic, they understood how efforts by Peter to replace his harm thoughts with rational arguments that he would not act on them could also be avoidance. They also agreed that his questioning of his parents about his potential for harm and their offering reassurance that the thoughts were irrational constituted avoidance. Additional rituals to neutralize harm thoughts were minimized by Peter and not pursued further during the discussion. Finally, the therapist helped Peter and his mother identify imaginal exposures to the intrusive thoughts of harming himself and others as the primary mode of exposure. In vivo exposures to handling sharp objects and being in close proximity to his younger siblings were identified as additional, or adjunct, exercises.

The focus on imaginal exposures to the thoughts of harming others followed from the earlier portion of conceptualization that identified these thoughts as the precipitating stimuli. Because these thoughts were cognitions, it would be understandable to classify them as anxiety-provoking beliefs or expectations. Specifically, sharp objects could be viewed as the precipitating stimulus, and the thought “I will stab someone” could be viewed as the expectation that made a safe object seem dangerous. However, such a conceptualization misses the fact that Peter’s thoughts were occurring without material reminders and that the thoughts were the primary source of fear. Moreover, such a misunderstanding would suggest that exposure primarily needs to be completed to handling sharp objects, which by itself is less likely to be effective. Another challenge in conceptualizing Peter’s symptoms involved separating thoughts of killing himself that elicited anxiety from thoughts that he would be better off dead, which were associated with helplessness and sadness. Whereas the former are targets for exposure, the latter are suggestive of developing depression secondary to OCD. These depressive thoughts required monitoring and efforts to improve mood and instill hope, primarily through successful treatment of OCD.

Parent Involvement

Planning the involvement of parents as exposure coaches was also covered in the first therapy session and presented a few challenges. From the beginning, Peter expressed reluctance to work closely with his parents, whereas his mother found the opportunity for her to be involved a significant improvement over their previous therapy experience. The therapist explained the potential benefits of teaching Peter’s parents to be exposure coaches. First, exposure therapy is difficult work, and Peter could likely benefit from parental assistance to regularly initiate and successfully complete at-home exposures. In addition, and equally important in this case, Peter’s parents were directly involved in his rituals by (p. 141) providing reassurance and would need to learn a different way to respond to him that promoted exposure rather than avoidance in a manner that was supportive and consistent with his progress in therapy. Similarly, exposures were likely to include his siblings or cousins, and his parents likely would need to facilitate these interactions. Finally, Peter appeared to have intrusive thoughts that he was embarrassed to reveal to anyone, including his parents. Sharing these thoughts with his parents likely would constitute an important exposure for him to learn that he was not a horrible person for having such thoughts.

On the other hand, the therapist acknowledged legitimate reasons to minimize parent involvement. First, at 15-years-old, Peter was appropriately interested in being independent and old enough to meaningfully convey his preferences for the design of his treatment. Not respecting his preferences would likely increase his resistance to therapy. Moreover, given the nature of his symptoms, specifically that sharing some of his thoughts reduced his anxiety, parent involvement in exposures could inadvertently provide reassurance. Specifically, if Peter’s parents were to coach him through exposures to his thoughts of harming others, he might attribute safety to their presence rather than the innocuous nature of the thoughts. As such, for treatment to be successful, Peter would likely have to complete exposures not only by himself but also without others knowing that he was completing them. The therapist clarified that the value of parent participation in the exposure depended partly on the expectations that lead to anxiety. For thoughts that Peter feared because they suggested he was dangerous, parental presence could function as avoidance by “preventing” harmful behavior. In contrast, for thoughts that Peter feared because they suggested he was a horrible person, parental presence increased anxiety and provided an opportunity to disconfirm his fears.

To balance the advantages and disadvantages of parental involvement, the therapist recommended beginning with modified parental coaching. Specifically, he recommended that Peter’s mother, or father when he attended, practice coaching exposures during the session to learn how to help when needed. However, Peter could conduct exposures on his own between appointments with scheduled check-ins with his mother twice a week to ensure he was staying on track. Neither Peter nor his mother thought adding rewards or consequences would be necessary. The therapist and family agreed to pursue this plan as long as Peter was progressing. If he was not conducting exposures or experiencing improvement in symptoms, they would revisit increasing the degree of parental involvement and possible reinforcement for his efforts.

Fear Ladder

The therapist built a fear ladder with Peter and his mother during the second therapy session. They began this process by reviewing the goal of exposure, which was to learn that thoughts are not dangerous in that they do not control his behavior or make him a terrible person. To learn the former, Peter would need to handle thoughts on his own, especially with objects and in situations that provided opportunities for harm, and see that he does not act violently. For the latter, (p. 142) in addition to learning that he was unlikely to act on his thoughts, he would need to share the thoughts with others to learn that others do not shun him. Each exposure would consist of repeating the thought over and over either aloud or silently and recording his anxiety every minute or so. Peter understood that he must resist asking for reassurance or trying to neutralize the thoughts cognitively. The therapist also reviewed the difference between parent support and providing reassurance. If Peter’s distress decreased and he did not behave violently, that would suggest that thoughts were not as dangerous as OCD currently had him believing.

The therapist then directed Peter and his mother to make a list of his intrusive thoughts, the situations that were troubling him, and other ways in which his OCD was causing problems. The therapist encouraged both Peter and his mother to contribute to the list because the perspectives of both of them were valuable, and it was fine if they disagreed about the importance of any individual item. Through this process, the therapist and family decided that it would be most helpful to create two fear ladders. The first listed the various thoughts that distressed Peter, and the second listed situations and objects that triggered thoughts or made thoughts more difficult for him to manage. This organization combined stimuli that functioned somewhat differently (i.e., precipitating fear vs. guilt), as well as separated thoughts from their related objects (i.e., harm thoughts from scissors) without specifying particular steps for combining them (i.e., repeating thoughts and then repeating thoughts while holding a knife). However, this strategy seemed to be the most concise manner in which to include all the items that needed to be addressed. The family felt confident that they could titrate the degree of difficulty posed by exposures through combining items as therapy progressed in the absence of a detailed plan.

As Peter began to create his fear ladder, it became apparent that adding thoughts to the list was upsetting and constituted an exposure in and of itself. As had been clear from the beginning, Peter had not revealed some of his intrusive thoughts to anyone because he believed they were too shocking and embarrassing to admit. The therapist explained that this difficulty was common and understandable. Over the course of completing the psychoeducation and creating his treatment plan, Peter had become more comfortable with the concepts of OCD and exposure therapy. As a result, he was now able to engage in a general conversation with the therapist regarding the undisclosed thoughts, which he acknowledged were sexual in nature. Because he was not ready to discuss the specifics of these thoughts, the therapist advised him to enter notes in the fear ladder that represented the different thoughts to him but were not interpretable to others. By the end of the session, Peter had a fear ladder to specific thoughts with a section for harm thoughts (killing a friend, stabbing himself, killing himself, stabbing a parent, choking his youngest sibling, stabbing his other siblings, and killing strangers) and one for sexual thoughts that included four unidentified items. He also completed a second ladder with objects (pens, forks, scissors, butter knives, and kitchen knives of various sizes) and situations (being alone, being with a parent, being with a friend, being with the family, and being with a sibling alone). The items were put in a general order of less to more distressing (as listed here), (p. 143) although Peter understandably had difficulty differentiating the difficulty level of some of his thoughts.

Sample Exposure

Soon after completing his fear ladder and beginning exposure, Peter conducted a series of exposures to a thought that was of moderate difficulty for him (i.e., stabbing one of his parents) that illustrates the general process through which his treatment proceeded. The first exposure was conducted in the office with Peter and his mother. It began with Peter repeating “I want to stab my mother to death.” Peter thought that stating “I want . . .” was more upsetting than “I will . . .” because he did not have an object to carry out the thought in the moment. Peter rated his anxiety at the beginning of the exposure as an 8 out of 10. He allowed his mother to query and record his anxiety throughout, although he frequently offered a rating before his mother asked. The interval between ratings ranged from approximately 30 seconds to 2 minutes. He began by repeating the thought out loud, and his anxiety gradually decreased to a 5 out of 10. During the course of therapy, Peter had learned that silently thinking about and picturing a thought was more realistic, and anxiety provoking, than repeating it aloud. When he switched to this modality, his anxiety increased to a 7. For the remainder of the exposure, Peter alternated between out-loud repetition and silent imagination until he felt his anxiety had decreased to 0. At the end of the exposure, Peter was able to state that he believed it was unlikely he was going to stab his mother, even if he concentrated on the thought of doing so. During the next week, Peter practiced this exposure at home. He preferred to start with his father present as a safety behavior, but he was eventually able to complete the exposure with his mother alone.

During the next session, Peter was willing to add a sharp object to his intrusive thought exposure. Again, he and his mother conducted the exposure with direction and assistance from the therapist. Peter held a sharp pencil and said to his mother, “I am going to stab you with this pencil.” The plan was for Peter to begin by sitting a few feet from his mother with the therapist in the room, gradually move closer, and then perform the exposure with the therapist out of the room. Peter believed he could manage the thought “I am going to stab you . . .” but that the thought “I am going to kill you . . .” would be too difficult. Because the immediate goal was to introduce the in vivo aspects of the exposure (the presence of sharp objects), the therapist agreed that it was acceptable to begin with a less distressing thought. With the therapist in the room, Peter began to repeat his thought while holding the pencil in front of him with his mother facing him. After his anxiety decreased a few points, he was ready to have his mother turn her back to him. During the next 5 minutes, he gradually moved closer until he was holding the pencil to his mother’s neck and repeating his thought, alternating between repetitions aloud and mental imagery. Peter then allowed the therapist to leave the room so that Peter could learn that he did not stab his mother because he did not want to do so, rather than because the therapist was there to stop him. The therapist first returned to the room after approximately 15 seconds to query Peter’s anxiety, which had increased significantly with the therapist’s departure. (p. 144) The therapist then left and returned approximately every 2 minutes to monitor Peter’s anxiety until it had decreased by half. To end the exposure, Peter noted that he did not stab his mother despite focusing on the thoughts while having the opportunity to do so and also that his anxiety decreased.

Course of Treatment

Peter attended 10 sessions during approximately 4 months. His initial ambivalence led to some missed appointments and extended intervals between appointments early in treatment. However, after 2 or 3 sessions in which he successfully completed exposures and then experienced a decrease in distress at home, Peter’s engagement increased substantially. He readily engaged in exposures during the session and consistently completed them between sessions. Throughout the process, he continued to prefer to be independent from his parents, completing most of his exposures between sessions on his own. However, he allowed his mother to participate during in-session exposures and to check in with her mid-week to ensure he was progressing as planned.

As described previously, the therapist and family were able to complete psychoeducation in the first therapy session and fear ladder building during the second. The therapist then introduced Peter to the active ingredient of treatment in the third session by having him complete an exposure to the thought of hurting a friend. This was a contrived thought that elicited minimal anxiety and allowed Peter to begin with success. During the same session, he successfully worked on a version of the thought, “I will accidently kill my friend,” that he actually experienced and found distressing. These introductory exposures were followed in sessions 4–6 by the exercises described previously for the sample exposure, including repeating the procedures with a knife after the pencil. By session 7, Peter and his mother felt confident they could handle violent thoughts. From this point on, Peter would complete an exposure to a new thought in session (e.g., “I want to choke my brother”) and then would repeat the exposure at home in proximity to his siblings and other appropriate objects or situational cues.

The next goal in therapy was to address the remaining thoughts that Peter had not disclosed. As a result of his success addressing his violent intrusive thoughts, Peter was more confident than at the outset of therapy that he could handle the remaining thoughts. He began this process by revealing his thoughts to the therapist individually during session 8. During this discussion, he described having thoughts about touching others inappropriately and having sex with them. These thoughts were generally vague without specific detail. The separate entries on his fear ladder corresponded to inappropriately touching or having sex with different people (i.e., strangers, friends, siblings, and parents). The therapist responded that such thoughts were common OCD symptoms but nonetheless understandably distressing. Peter and his therapist decided that to address his fear that he was a bad person and would be shunned by others, it was important to reveal the nature of his thoughts to his mother, which he did during that same session. Afterward, Peter reported feeling considerably relieved and was confident that (p. 145) he could address these symptoms on his own through thought exposures and eliminating avoidance.

By the end of treatment at the 10th session, Peter’s OCD symptoms were in remission. The frequency with which he experienced thoughts was greatly diminished. Moreover, when he had intrusive thoughts, he was able to dismiss them or realize they were “just thoughts” and not dangerous. When necessary, he was able to do impromptu exposures, which were successful. His mother agreed Peter was no longer asking for reassurance nor avoiding sharp objects or his siblings at home. The time he spent alone in his room also appeared to be age appropriate because he was interacting with his family and leaving his room when asked. Although his mother described him as managing OCD on his own, she felt confident that she knew how to help him conduct exposures and that he would continue to accept her support. The therapist then reviewed the likelihood that symptoms would increase from time to time and that they should be prepared to revisit planned exposures when needed. They ended treatment with a reminder that the family was welcome to return whenever needed.


Peter’s case illustrates a number of principles important for the delivery of exposure therapy. First, the nature of his symptoms highlights the importance of an accurate functional assessment and conceptualization. As discussed previously, the design of an effective treatment plan centered on thought exposures was contingent on identifying intrusive thoughts as the stimuli that set off Peter’s anxiety. These thoughts were contrasted with suicidal ideation based on an understanding of the precipitating factors and resulting emotions. Similarly, although not discussed previously, OCD harm-related thoughts must be, and were in Peter’s case, distinguished from aggressive thoughts associated with actual risk of harming others. Specifically, the latter thoughts are precipitated by believing one has been mistreated and feeling angry and then the thoughts are followed by hostile actions or a desire to follow through on those thoughts. In contrast, OCD intrusive thoughts of doing harm are unprecipitated, or precipitated by innocuous stimuli such as the presence of scissors, and lead to feelings of fear and a desire to protect others from oneself.

A second point of discussion surrounds the delivery of the thought exposures. The content of Peter’s thoughts—committing harm and inappropriate sexual behavior—would be distasteful, if not distressing, to most people. Accordingly, parents and therapists may be understandably hesitant to encourage youth to repeat such thoughts, especially when the content of thoughts is not age appropriate. Therapists should keep two principles in mind. First, youth can be encouraged to complete exposures to any intrusive thought they are having, but they should not be encouraged to generate more offensive thoughts. Specifically, if a thought has become entrenched in an OCD cycle of avoidance, then exposure is appropriate no matter how offensive or upsetting the thought is. Avoiding such thoughts places youth at risk for continuing to suffer. On the other hand, especially when working with younger children, therapists and parents are often (p. 146) able to generate new, more extreme, content than that of the child’s thoughts. It is not necessary, nor advisable, to introduce a child to thoughts or examples that they have not experienced already. The second principle is to always keep parents involved. Thought exposures to sensitive topics will generally be more successful if the therapist first ensures that the parent understands and agrees with the rationale and plan. It is often helpful to have such conversations outside the child’s presence to allow parents to freely discuss concerns at the beginning of therapy and again when additional sensitive topics arise.

Peter’s course of treatment provides a clear example of the traditional use of thought exposures for the treatment of OCD. The next case example explores how to apply these concepts to more routine worries in the context of generalized anxiety disorder (GAD). In addition, we further discuss considerations for combining thought and in vivo exposures.

General Worry and Anxiety


Sam was a 10-year-old fifth grader who presented for evaluation on referral from his pediatrician who had seen him seven or eight times in the past 6 months for various somatic complaints. The pediatrician suspected anxiety was influencing Sam’s physiologic distress and symptoms, as well as a reluctance to attend school. At the initial evaluation with the therapist, Sam’s father shared that Sam had been a colicky baby, had some difficulties separating from his parents when starting preschool, and tended to be stressed around anticipated transitions such as the beginning of each school year. Sam and his four older siblings had experienced the loss of their mother in an accident when Sam was 7 years old. Sam had appeared to have more difficulty with his mother’s death compared with his siblings, and his father described spending substantial energy checking in with how Sam was doing and providing reassurance for Sam’s many “What if . . .” questions. He had allowed Sam to sleep in his room for the past 2 or 3 years. The family had tried to transition Sam to sleeping in a room with his brother without much success. Sam frequently came out of his room to find his father and asked repeatedly to sleep in his father’s room. If his father insisted he stay in his room with his brother, Sam would be awake for hours before falling asleep. No matter where he slept, Sam was frequently tired during the day, prone to headaches, and complained occasionally of difficulties concentrating in class and while doing homework despite teacher reports of solid academic work and attentive, cooperative behavior at school. His difficulties seemed to have worsened during the past 9–12 months.

On questionnaire and diagnostic interview, Sam endorsed frequent worrying, most days. Typically, he would try to push the worries aside, stay busy so he would not “think too much,” or seek reassurance from his father; however, the worries tended to resurface especially during down times such as at night. Sam was described as having many “What if . . .” questions and thinking the worst-case scenario for “everything.” His most frequent worries revolved around school (p. 147) and sports performance (he played in a youth recreational basketball league), the possibility of break-ins or school shootings (although his home and school had professional security systems and no history of break-ins), transitions, and new/unfamiliar situations and activities. With his schoolwork, he was perfectionistic, and due to worry that he would not perform at the top of his class, he would spend an hour longer on homework than his siblings did at the same grade level in order to check his work or rewrite answers. If he did not perform up to his high expectations in basketball, he would shut down and refuse to speak with his coaches, teammates, or family, even though all expressed expectations he need only give his best effort and focus on fun rather than scoring or winning. Multiple “What if . . .” questions routinely preceded upcoming transitions and in anticipation of doing something new or going somewhere unfamiliar. The family had recently taken a vacation, and Sam needed to know ahead of time every detail of the trip, including where they would be staying, how they would get to and from the airport, and what kind of snacks would be on the plane. At night, he tended to think a lot about how things would go the next day, and he would review in his head whether he had completed all his schoolwork to his standard. He expressed feeling calmer in his father’s room at night. He would worry about things more in his room that he shared with his brother, and when falling asleep in that room after his brother had quickly fallen asleep, he would be alert for the slightest sound, worrying that someone might be trying to get into the house to rob them or hurt someone in the family.

When asked about the loss of his mother, Sam expressed that he missed her and was sad when he experienced major milestones without her. He experienced a variety of emotions in response to memories of her but did not endorse symptoms suggestive of complicated grief or post-traumatic symptoms. He worried some about how is father was dealing with being a single father of four children (although he reported no concrete evidence of maladjustment on his father’s part) but did not worry about a similar accident befalling his father and was able to leave for school and stay home with siblings while his father was out without any more distress than his usual worries caused. Although he could be irritable at times, especially if he had not slept well or was particularly worried or stressed, neither he nor his father endorsed any episodes of persistently low or irritable mood.


The therapist discussed with Sam and his father that Sam’s symptoms best fit a diagnosis of GAD. Sam’s father had been thinking of Sam’s distress as primarily stemming from the loss of his mother. However, upon discussion, he agreed that although the loss was difficult and upsetting, Sam’s current distress and functional impairment related to frequent and persistent worry about a broad range of topics, most of which did not relate to his mother. Although worry is a common experience, Sam had been worrying nearly daily and to a degree that worries were difficult for him to dismiss and led to difficulties sleeping, low energy, muscle tension in his neck with associated headaches, irritability, and concentration problems. Worry and his efforts to manage anxiety and worry made it difficult for him to (p. 148) engage in and enjoy his daily activities. After explaining this distinction, the diagnostic description of GAD made more sense to Sam’s father. To Sam, the description of GAD was quite readily seen as fitting his experience.

The initial evaluation appointment concluded with the recommendation that Sam participate in parent-coached exposure therapy. This therapy was briefly introduced by the therapist as a way of facing fears that would “take the power out of worry.” Basically, avoidance of bothersome thoughts can make them “a bigger deal.” By spending time focusing on the worry thoughts through structured exposures, Sam would get more bored than bothered by the thoughts. Sam wondered aloud how exposures to his thoughts would differ from his everyday experience of having worry in his head. The therapist explained that exposure would be different in that Sam would be thinking the thoughts without distraction or other relief tactics so that he would have sufficient time to get used to and bored with them. Sam was skeptical but willing to give it a try in hopes of feeling better. His father expressed concern that the therapy approach would further stress Sam out but was willing to try it because the explanation made sense and efforts to calm and reassure Sam had not worked well. For management of somatic complaints, the therapist recommended lifestyle modifications such as improving sleep hygiene (e.g., refraining from screen use 1 hour before bedtime), maintaining regular daily physical activity, and redirecting attention away from physical complaints to daily activities and interests. Although they could spend some time on brief instruction and goal-setting to support Sam’s implementation of these self-care recommendations, the primary focus of therapy would be on exposures.

In the first treatment session, the therapist presented education about the avoidance cycle of anxiety and helped Sam and his father apply it to Sam’s worry. First, they identified triggers, or precipitating stimuli. Primarily, Sam’s anxiety was set off by worry thoughts, such as worrying about school performance, not doing well enough at sports, or that someone would break into the house. Sometimes, the thoughts were associated with environmental stimuli, such as having an assignment to do, missing a shot during a basketball game, or sounds at night; other times, the worries seemed to pop up out of the blue. Initially, Sam had difficulty articulating beliefs related to these situations other than that he had to do “his best” at school, work, and sports. With more questioning, Sam verbalized that mistakes on his schoolwork would prevent him from doing well academically and qualifying for scholarships to attend college so that he would end up working in the fast-food industry and not be able to support a family. With sports, he feared that he would lose the esteem and respect of his coaches and teammates. At the therapist’s prompting, Sam and his father agreed that it was accurate to summarize Sam’s anxiety-causing expectations as (1) believing it was likely his worries would come true and (2) that he could not handle thinking about his worries for very long.

Sam and his father initially were not sure how avoidance applied to Sam’s worries because he was actually highly engaged in his schoolwork and sports. Avoidance became clearer as the therapist explained the function of spending too much time on schoolwork (including checking and redoing assignments) and extra basketball practice as safety behaviors that gave him a false sense of protection (p. 149) against his fears of poor performance. Also, as they talked more about worries at nighttime and with unfamiliar situations and transitions, they identified distraction (e.g., trying to think of other things and using electronics) and reassurance seeking (e.g., asking his father for details on what to expect) as other safety behaviors that served the function of avoidance. Based on the understanding that worry thoughts were the primary stimuli that precipitated anxiety and identification of Sam’s methods of avoidance, the family identified broad exposure goals of completing thought exposures to feared outcomes without distraction or reassurance seeking. In addition, he would work toward reducing time spent on schoolwork and practice completing schoolwork imperfectly, as well as set goals to transition to independent sleep. Thought exposures would be important not only on their own but also in accomplishing the latter two goals.

Parent Involvement

Sam was motivated and willing to engage in exposure therapy; however, like many young people seeking treatment for anxiety, his habits of avoidance and safety behaviors were strong, and having his father participate in therapy would be important for getting exposures completed. Furthermore, following the psychoeducation session, Sam and his father were more aware of how some of their interactions were part of Sam’s avoidance cycle, particularly around reassurance seeking and reliance on his father’s presence for comfort at night. His father also realized that although he was generally firm about expectations for cooperative behavior and followed through with mild consequences for misbehavior or noncompliance, he had relaxed expectations in situations in which Sam could become anxiously distressed or was feeling unwell. He expressed to the therapist a desire for guidance on how to be understanding and supportive without falling into the avoidance and safety behavior cycle. The therapist recommended that Sam’s father participate in therapy so that they could jointly develop a fear ladder that defined expectations for gradually facing fears rather than avoiding. In addition, Sam’s father could learn how to coach Sam through exposures so that he could practice being firm and supportive around facing fears. They further agreed to work on a behavior plan to solidify expectations around completing exposures and meeting functional expectations (e.g., adhering to homework limits and meeting independent sleeping goals), create a point system and rewards for meeting expectations, and implement mild logical consequences if Sam failed to complete a planned exposure or meet a functional expectation. Sam’s father readily understood the concepts behind the behavior plan and expressed confidence that with the additional practice of exposure coaching he would be able to integrate the behavior plan for encouraging exposures and brave behavior into his usual parenting.

Fear Ladder

During the second therapy session, the therapist worked with Sam and his father to create fear ladders to guide exposure therapy. The therapist encouraged Sam (p. 150) to start his fear ladder by creating a list of worry thoughts that bothered him. As Sam created this list, it became apparent that a significant portion of his worries revolved around performance, so that was identified as one fear ladder. Nighttime worries constituted another fear ladder. A third fear ladder list was made for “miscellaneous” worries that included various worries about bad things happening and being unprepared for the unexpected when facing new or unfamiliar situations.

For the first performance-oriented ladder, the therapist guided Sam and his father to list exposures that would help Sam face his identified fears of poor school performance leading to negative future outcomes and poor sports performance leading to loss of esteem. This list first included the worry thoughts Sam had initially written down, in general order of difficulty. Because Sam expressed uncertainty about being able to tolerate thought exposures about negative future ramifications of poor school performance, the therapist guided him to list more proximal feared outcomes first and the more distal outcomes as higher on the fear ladder. Because Sam’s perfectionistic safety behaviors were interfering with his ability to learn that normative mistakes are not harmful, the therapist encouraged Sam to include exposures to making mistakes on schoolwork and during sports. Sam was clearly anxious about these elements, but he eventually added turning in a writing assignment with grammatical errors as a highly difficult exposure, as well as easier exposures of making mistakes on a practice worksheet (not assigned by the teacher) and then on a worksheet/assignment worth only a few points. Following the therapist’s suggestion, he added reduced homework times to the list. Easier items included completing single assignments within a time limit and/or without checking them and turning them into an adult for grading (parent or therapist was easier, and teacher was more difficult). Based on his father’s estimate that Sam should be able to complete homework within 1 hour, rather than his usual 2 hours, they included exposures of limiting homework time to 1.5 hours, then to 1.25 hours, and then to 1 hour. For sports, he added items such as intentionally missing a shot (easier) and dribbling off his foot (more difficult). The therapist explained that integrating thought/imaginal exposures and in vivo exposures would be important so that Sam could better learn that the worry thoughts that he so often experienced were not harmful and did not forecast the future. Furthermore, by purposefully allowing himself to experience feared negative outcomes that are part of the normative human experience, such as mistakes, he would learn they were tolerable and also not to be feared. Finally, the therapist explained that combining thought exposures with in vivo exposures would simulate Sam’s usual experience of having worry thoughts during situations such as turning in homework or making mistakes and help him learn that neither the situation nor the thoughts are harmful.

The fear ladder for nighttime worries proceeded in a similar manner. First, Sam listed worry thoughts he tended to have at night (e.g., intruders and creepy things in the shadows) and integrated in vivo exposures of being alone in his dark room while practicing worry thoughts, looking at shadows, and listening to creepy noises, first during the day and then at night. As part of his nighttime fear ladder, Sam and his father negotiated a transition to independent sleep that included first (p. 151) sleeping on the floor in his father’s room and then sleeping in his own room, initially with his father checking in every few minutes and transitioning to less frequent checking. The purpose of these exposures would be for Sam to learn that he could have thoughts of bad things happening at night and even feel scared and could handle those thoughts and feelings independently.

For the final “miscellaneous” fear ladder, Sam listed, in general order of difficulty, imaginal exposures to bad things happening (e.g., school break-ins and school shootings) and ways to practice handling the unfamiliar without reassurance seeking or getting details ahead of time. For the latter, Sam identified that he was worried that he would not be able to handle it if something bad or unexpected happened. Thus, fear ladder items included planning to go for an outing without knowing where, making plans and knowing that his father would change them, and going someplace new and not having information about it ahead of time. For each of these exposures, they agreed ahead of time that Sam’s father would answer “I won’t answer that” if Sam sought reassurance and that Sam would earn points for refraining from asking questions about the activity or seeking reassurance from his father from the start to the conclusion of the exposure. The exposures in this category were designed to further reinforce that Sam could experience worry thoughts and imagine bad things happening without them coming true, that he could handle the thoughts and distress independently, and to build his confidence that he could handle the unexpected.

Sample Exposure

Sam was eager to reduce stress related to school performance worry and started with several imaginal exposures in the first couple of therapy sessions. He also practiced these thought exposures at home. During the fourth therapy session, the therapist helped him and his father set up an exposure to his worst imagined outcome from a poor grade by instructing him to write out a brief (three to five sentences) story depicting his worst fears coming true. As part of setting up the exposure, the therapist asked Sam what he thought would happen. Sam said that he was afraid that writing out this story would make him so anxious that he would not be able to handle it or that the anxiety would never go away if he kept thinking about his fears coming true. He rated his anxiety prior to writing the story as an 8 out of 10. In creating the story, the therapist instructed Sam to write about a bad grade coming true. She coached Sam to write things in the present tense and change phrases such as “I would be” to “I am.” Sam wrote,

I get the assignment back. It isn’t good. I got a D and the teacher wrote on the paper that I should have checked my spelling. Because of bad grades, I do not get into college and cannot get a good job. I turn into a grown up whose dad has to pay for everything and makes me live in his basement. I’m such a loser.

The therapist instructed Sam to repeatedly read the story aloud and asked him after every few times through to rate his anxiety, which started at a 7 prior to (p. 152) reading the story the first time and declined to a 2 after reading the story for approximately 15 minutes. Following this exposure, the therapist asked Sam if his fear had come true and what happened to his anxiety. Sam responded that his fear of getting anxious did come true but that his anxiety eventually came down and he was able to handle it, despite his prediction that anxiety would not go down or would be too high to handle.

After practicing this exposure between sessions with his father during the following week, Sam reported that even the more difficult thought exposures did not bother him much and he was starting to view some of the thoughts as “ridiculous” and not likely to come true. He expressed feeling ready to combine the thought exposures with an in vivo exposure but was clear that he did not wish to be pushed “too hard.” He and his father opted to start with completing a mock math assignment with an intentional mistake. Sam asked the therapist to pretend to be the teacher and “grade” the assignment by marking which answers were correct and incorrect. Sam predicted that these actions would trigger worries about not getting into college; thus, he decided that he would combine the in vivo exposure with the thought of “Now, I won’t get into college. My dad will have to pay for my things forever. I’ll be a complete loser.” Although he had practiced similar thoughts many times in the past several weeks and could identify that the outcome was not likely, Sam rated his anxiety as 6 out of 10 at the start of the exposure. His anxiety remained elevated at approximately 4–6 while he completed the assignment and turned it in. The therapist graded it, marking with red the two items answered incorrectly, and handed it back to Sam. Sam looked at the paper with the red marks and said his thought repeatedly out loud. During this time, Sam’s anxiety reduced and he started laughing while stating his worry thought. Sam and his father concluded the exposure when Sam’s anxiety decreased to a 1 and he appeared quite relaxed. Sam’s father followed the procedure they had practiced for wrapping up exposures by asking Sam if his fear had come true and what happened to his anxiety. Sam responded that his fear of making a mistake did come true and that it did trigger the worry thought about not getting into college but that he could handle it and his anxiety decreased very quickly. He described that the anticipation was far worse than the actual outcome. Furthermore, he reported that because he had practiced very similar imaginal exposures prior to this one, he quickly became bored with the thought and even found it funny because after having said the thought so many times, he realized that the college admissions people would probably not care about or even know about this non-graded assignment.

Course of Treatment

Generally a people pleaser, Sam tended to be more cooperative in sessions with the therapist than for exposures with his father between sessions. Thus, the therapist’s support of the father’s use of a behavior plan to reinforce Sam’s engagement in exposures (and discourage his avoidance of exposures) was essential to maintaining his progress. Fortunately, Sam’s father tended to be authoritative in much of his parenting and benefited from “permission” to apply his usual (p. 153) parenting approach around behavioral expectations to Sam’s engagement in exposures in and between sessions.

Following the initial in-session exposures with mock assignments, Sam and his father continued to do similar exposures throughout the week, completing various mock assignments and having different adults “grade” them—including his teacher. Sam was able to report that making mistakes on mock assignments no longer bothered him and that he was becoming bored with thoughts about negative future outcomes for poor school performance. However, his father noted that Sam continued to do a lot of checking of his assignments, leading him to spend too much time on them. Sam acknowledged that he was still afraid of making mistakes on assignments that “counted.” The therapist encouraged Sam to move forward with items on his fear ladder that limited completion time or involved errors on actual assignments. Sam thought that if he started with time limits, he would get hung up on whether he had made errors and, with his father’s agreement, opted to start with turning in an assignment with a minor error and then more substantial errors and then work on homework time limits. They set up and completed these exposures in a very similar way as the sample exposure. That is, Sam identified the worry thoughts that would likely be triggered by the action and repeated those thoughts as part of the in vivo exposure.

For more difficult in vivo exposures, Sam followed the therapist’s suggestion of doing a thought exposure prior to doing the combined in vivo–imaginal exposure. Knowing that reducing homework time would be difficult for Sam, at least initially, his father followed through with the behavior plan. He awarded Sam 1 point for each day that he put his homework away within the time limit. There were also a few times during this process when Sam’s father needed to follow through with the planned consequence for Sam exceeding the time limit—that is, Sam needed to create an additional intentional error in the assignment on which he was working. After several weeks, Sam had reduced his homework time to 1 hour most days and reported feeling less stressed about his school performance on typical days. Because he had integrated some sports performance exposures between sessions, he also reported feeling more relaxed though still competitive in sports and better able to have fun. His father observed that Sam was quicker to recover from errors during practice and games and, as a result, was better able to encourage and cheer on his teammates. Sam reported that he noticed he was more stressed and likely to resort to checking and other safety behaviors when stakes were higher (e.g., more important tests and games) but believed that what he was learning through exposures was helping with the worries he experienced during those times.

As his distress around school and sports performance improved, Sam and his father turned toward nighttime worries and independent sleep. At this point, they were 1½ to 2 months into treatment and believed they had mastered imaginal and in vivo exposures. The role of the therapist shifted around this time from providing direct guidance in how to plan and complete exposures to serving as a sounding board as Sam and his father worked through Sam’s hierarchy for nighttime fears and miscellaneous fears and worries. Because of the previous practice (p. 154) with imaginal exposures, Sam and his father easily designed imaginal exposures around some simple thoughts about break-ins and creepy things in the dark, followed by imaginal exposures to his worst fears coming true. Sam and his father opted to alternate between doing imaginal exposures only and doing imaginal exposures combined with in vivo exposures of being alone in the dark in his room while either looking at shadows or listening to creepy noises played on a tablet, working their way from easier thoughts to more difficult thoughts. After completing a few imaginal exposures of this type, Sam and his father started following a time line for independent sleep they had set up with the support of the therapist. Again, knowing this process would be challenging for Sam, Sam’s father used the behavior plan to reward brave behavior of staying in his room and avoiding reassurance seeking, and they planned that if Sam came out of his room after bedtime, he would forfeit tablet privileges the next day. Knowing that electronics had served as a safety behavior and interfered with good quality sleep, Sam turned the tablet over to his father 1 hour before his bedtime every night.

Toward the end of this process, Sam and his father were feeling confident in their ability to complete exposures, follow the fear ladders for nighttime worries and miscellaneous worries, and use the behavior plan to encourage Sam’s continued cooperation. As such, therapy sessions were spaced further apart, every 2 weeks initially and then once a month until they had met their initial treatment goals and could verbalize a plan for how they would use the skills they learned in therapy to maintain gains and approach relapse.


Sam’s case illustrates several important points regarding exposure therapy for generalized anxiety and worry. First, many of the common fears experienced by individuals presenting with GAD do not lend themselves easily or naturally to in vivo exposure. Very often, individuals worry about events that are of very low frequency (e.g., break-ins), events that would be distressing to anyone (e.g., school shootings and the death of family members), or events that are distal outcomes to a proximal event (e.g., not getting into college because of a bad grade in junior high or high school) so that creating an in vivo exposure experience would be impractical, impossible, or harmful. Imaginal exposure is a very useful, although underutilized, tool for these types of worries and fits with conceptualizing GAD from an avoidance and safety behavior perspective. By understanding GAD within the avoidance model of anxiety, the worry thought is the stimulus that provokes anxiety because of a belief that the feared event is likely to come true or that the thought will create unmanageable anxiety that must be avoided or alleviated. Thus conceptualized, imaginal exposure is not just a practical alternative to in vivo exposure; it is the indicated exposure. To learn that worry and thoughts about bad things happening are tolerable, individuals with GAD must engage in thought/imaginal exposures repeatedly until the thoughts no longer elicit high levels of distress.

Conceptualizing GAD with the anxiety cycle brings to light how the process of worry in and of itself can serve as avoidance. That is, as an individual worries, (p. 155) she may jump from worry to worry, moving on to the next worry before the first worry can be fully considered or “faced.” In our practice, we have observed anxiety sometimes remaining high during imaginal exposures that include multiple different worry elements or if the individual mentally moves on to other worries before completing the exposure to the first. In these cases, coaching the individual to focus more deeply and consistently on a single element and track their anxiety about that element can lead to a more successful exposure. Future, more challenging, exposures can then integrate multiple worries.

The avoidance conceptualization of generalized worry also brings to light safety behaviors that can be addressed through exposure and response prevention, such as reassurance and proximity seeking, distraction, perfectionistic behaviors, and even self-reassuring. Interestingly, the exposure and response prevention approach runs counter to coping strategies that parents might instinctively encourage and that therapists commonly teach in the treatment of anxiety disorders. Instead of challenging worry thoughts with evidence for and against, utilizing coping thoughts when anxious, or practicing various forms of distraction, the exposure approach is to purposely have the worry thoughts and imagine the worst feared outcome repeatedly without safety behaviors. Once the avoidance conceptualization is understood, it is clear that thought/imaginal exposure is necessary to learn that anxiety-provoking thoughts are not dangerous and can be tolerated and that commonly thought of “coping” skills can inadvertently maintain the anxiety cycle when they function as avoidance.

Finally, the case of Sam also illustrates that in vivo exposures remain an important part of treatment, particularly in terms of learning that situations that often set off worry can be tolerated. Sam dealt with some of the most common worries we observe in our practice among youth with GAD—that is, worries about negative outcomes stemming from poor/imperfect performance and fears of not being able to handle or tolerate the unexpected. In both cases, it was helpful for Sam to engage in actives that convincingly evoked his worries with the goal of learning that situations that trigger worry thoughts are tolerable. As such, combining thought exposures with in vivo exposure to situations that triggered worry thoughts (e.g., being alone in the dark, hearing creepy noises, and making mistakes) was very important to his progress.

Case Examples: Interoceptive Exposure

Panic Related to School Anxiety


Maddie was a 15-year-old sophomore brought in by her parents for evaluation and treatment due to concerns about school attendance. Prompting the initial visit was a notice from the school that the number of missed school days had triggered the truancy process. Maddie identified that extremely uncomfortable anxiety had been preventing her from attending school—initially a few classes (p. 156) and then increasing to the point that she had not attended for the past 6 weeks. In seeking treatment, her parents expressed a desire for her to feel more comfortable in the school setting and wondered if homebound schooling would be recommended until Maddie started to feel better.

In gathering further information, the therapist learned that Maddie had historically been a strong and conscientious student who enjoyed the academic and social aspects of school. She had been involved in community theater, rock climbing, and playing guitar as hobbies. Within the first few months of ninth grade, Maddie started to express reluctance to go to school and complained of feeling vaguely unwell and uncomfortable. At first, the family attributed it to normative adjustment to high school and a particularly stern biology teacher (symptoms were first noticed in biology class). Maddie expressed feeling anxious or nervous but had difficulty identifying any specific reasons for anxiety other than worrying that she would feel unwell at school. Anxiety symptom complaints and visits to the nurse increased noticeably during her freshman year, triggering a referral to the school counselor. Maddie met a few times with the counselor, whom she said was very nice and a good listener. The counselor recommended distraction and using a grounding technique whenever Maddie felt anxious, and if that did not work, she was welcome to come to the office to see the counselor or take a break before returning to class.

When symptoms did not improve, Maddie’s parents took her to a therapist in the community. For a while, Maddie diligently attended weekly therapy sessions and practiced diaphragmatic breathing and other relaxation techniques daily so that she could use them to manage anxious feelings when they arose. The therapist encouraged Maddie to “face her fears” and go to school anyway. They made plans for what she could do when anxious, and she carried around lists of skills she could use. Maddie very much wanted to return to her normal school attendance but struggled increasingly more to stay in school and over time to go altogether. Eventually, she verbalized that “nothing worked” and made many arguments for why it was better for her to be homeschooled. Her parents expressed uncertainty regarding what they should do. On the one hand, the family had always valued education, and they wanted to encourage her to stay in a brick-and-mortar school for both education and socialization purposes. On the other hand, they saw how distraught she was about going to school and did not want to force the issue for fear of putting her over the edge of discomfort she could handle and also for fear of coming across as “mean” or not understanding, which Maddie now often accused them of being.

During diagnostic interview, Maddie endorsed symptoms of panic occurring in rapidly escalating episodes that included increased heart rate, difficulty breathing, feeling hot and flushed, dizziness, and chest tightness. Panic attacks had been occurring since the fall of ninth grade, peaked at a maximum frequency of five or six episodes a day while attending school more regularly, and decreased to approximately three or four episodes a week since she had not been attending school. Maddie identified triggers to these panic attacks as being in school, thinking about school, or “randomly” (i.e., without apparent trigger). She reported that her main worry about going to school was that she would feel anxious to the point that it would spiral out of control and she would not be able to pull herself together. She (p. 157) had started worrying about missing assignments and the effect that would have on her grades as well as the potential for punishment due to truancy, but otherwise she did not worry excessively about school performance and had always been comfortable with the social aspects of school. Maddie noticed that she had begun to dislike crowds since her anxiety started, which led to her avoiding running errands with her mother and turning down invitations from friends. She told the therapist that things were getting worse because a few panic attacks had now occurred outside the school context.


The therapist explained that Maddie’s symptoms met criteria for panic disorder with agoraphobia. This diagnosis did not come as a surprise to Maddie or her parents because this had been the diagnosis provided by her previous therapist. When the current therapist recommended exposure therapy, the family grasped the concept of Maddie needing to face her fears to overcome anxiety. However, they believed that Maddie had tried to do so by attending school, an approach that had been unsuccessful because she continued to have anxiety attacks that prevented her from staying in school. The therapist acknowledged their concerns and briefly explained that to be effective, exposures would need to directly address her panic symptoms, which the previous therapy had not. The family indicated their understanding and agreed to return for a second visit so that they could learn more about anxiety and how modifications to the previous approach had the potential to be more successful.

When the family returned for the second session, the therapist worked with them to apply the avoidance cycle to understand Maddie’s symptoms (Figure 8.1). Maddie quickly identified going to school and being in school as triggers for anxiety attacks. The therapist noted that, as is typically the case for panic disorders and based on the history she provided in the initial session, the primary precipitating stimuli were the panic symptoms themselves and that over time she had associated school with those symptoms and, thus, physical symptoms and school-related stimuli would both be considered triggers in her anxiety cycle. Maddie reported that when her panic symptoms began, she would have thoughts such as “Here we go again. The anxiety is coming. I have to get out of here!” When the therapist inquired as to whether Maddie’s belief was that something bad would happen because of the symptoms and/or that she could not handle the symptoms, she replied that the latter was very much the case for her. Specifically, it was her experience that anxiety would not go away unless she left the room and that she often needed to go home to obtain relief. Other than thinking anxiety would not subside as long as she stayed in the situation, she had no other fears of what would happen during or as a result of panic attacks.

Figure 8.1 Maddie’s anxiety cycle (panic).

Figure 8.1 Maddie’s anxiety cycle (panic).

In identifying means of avoidance, Maddie acknowledged that leaving the classroom, going home, and refusing to go to school or other places outside of the home were all forms of avoidance. The therapist then provided psychoeducation on safety behaviors and how they function as avoidance by preventing her from learning that the situations are safe enough to handle without special precautions. (p. 158) Maddie and her parents recognized several of the examples the therapist provided as ones Maddie had been engaging in and had even been encouraged to use, such as distraction, reassurance seeking from the school counselor and parents, and mentally scanning her body for signs of symptoms. When the therapist suggested that relaxation exercises could also function as avoidance, the family was inquisitive because they thought this was a coping skill for managing panic symptoms. The therapist explained that relaxation exercises can be effective tools for physiologic self-regulation but that when used to try to prevent or deal with panic symptoms, their use can reinforce the anxious beliefs that panic symptoms are dangerous and need to be avoided. The therapist explained that the overall purpose of exposure would be to help Maddie learn through her experience that panic symptoms were not dangerous and that she could handle experiencing the discomfort of them. Maddie was notably anxious thinking about treatment in this way because she had doubts about being able to manage her panic attacks. In addition, she thought treatment was intended to reduce anxiety, not to make her more anxious. Furthermore, she verbalized that she did not think she could manage a panic attack without using relaxation. The therapist acknowledged her (and her parents’) apprehension as normative and made it clear that they would create a plan that would break this task down into smaller steps.

Parent Involvement

Parent involvement was essential in Maddie’s case for a number of reasons. First, her motivation to engage in treatment was minimal. She had become quite (p. 159) skeptical of whether treatment could help her, as prior interventions had been minimally effective. She liked the relaxation techniques and believed that she did not need sessions to help her with those skills (and the therapist agreed that would not be a focus of treatment). Further reducing motivation was many months of experiencing avoidance as the primary, if not only, means of symptom relief, albeit temporary. Her parents would need to be involved to encourage and reinforce her participation in exposures both in and out of session. A second reason parent involvement was critical was her parents’ involvement in the avoidance cycle. By allowing her to come home or stay home, they had been facilitating avoidance. Understandably, they had felt forced to acquiesce to her insistence on being at home. If they did not, she would “lose it,” becoming so emotional and anxious that she would curl into a sobbing pile on the floor and, when she was composed enough to speak, would complain about how they were “heartless” and did not understand what it was like to have anxiety.

Maddie’s mother attended the majority of the subsequent treatment sessions with Maddie and explained that her husband’s busy work schedule kept him from traveling to appointments. She described him as supportive but anticipated that much of the work would be “on [her]” because she was the one primarily at home with Maddie and her siblings. Anticipating difficulty in getting Maddie to subsequent sessions now that she had a better sense of what exposures would look like for her, the therapist met separately with Maddie’s parents at the end of the first therapy session to outline a simple behavior plan for session attendance. The therapist recommended that they be clear that her participation in therapy was her responsibility and that if she attended and participated in all session activities, they would allow a preferred activity following the appointment (e.g., a trip to get frozen yogurt, “window shopping” at the music store, or undisturbed free time for 30 minutes after dinner). If she refused to attend sessions, access to her phone and tablet would be restricted until she attended a session. Consistent with the therapist’s prediction, Maddie’s mother called during the time of their next scheduled appointment and stated that Maddie refused to get into the car to come to the appointment. The therapist encouraged her to enforce the consequence of removal of tablet privileges. Unfortunately, follow-through was very difficult. When the therapist checked in later that week, Maddie’s mother reported that she removed electronics for approximately a day but let Maddie have the tablet back early because she promised to attend the next session.

The day before the next appointment, Maddie’s mother called the therapist again, stating that Maddie was refusing to attend. The therapist first confirmed that Maddie’s mother continued to be concerned about the course that this was taking and the effect of anxiety on Maddie’s school participation and engagement in life generally. Then the therapist reiterated the parents’ main job at this point was to get Maddie to a session where she could complete exposures so that she could learn it would not be as bad as her anxiety predicted. The therapist recommended Maddie’s parents be clear that if she did not participate in sessions, they would seek a higher level of care for her, such as an intensive outpatient placement, and that they would no longer call in to excuse her school absences (p. 160) unless she had a fever or clearly contagious illness. This latter point took convincing from the therapist, who explained that even if these actions led to truancy, the process would be uncomfortable but could also activate resources to support the parents in getting Maddie to school.

Maddie did come with her mother to the next scheduled appointment. Her mother reported with much relief that Maddie seemed to change her mind about attending when she overheard her mother contacting local intensive outpatient programs. Maddie’s desire to avoid this type of program got her to the next several sessions. In addition to weekly therapy sessions focused on exposure, the therapist scheduled a parent-only session in which she worked with Maddie’s mother to create a behavior plan that allowed Maddie to earn points for each session attended and each exposure completed (in-session and at home) and identified privileges that would be “on hold” if she refused to attend a session or complete an assigned exposure (i.e., no tablet and phone, no guitar, or no social activities) and would be reinstated after she attended a session or completed the assigned exposure. Furthermore, they clarified that school attendance was expected and made a plan for making staying at home unrewarding in that if Maddie came home or stayed home from school, she would be expected to work on schoolwork during school hours and privileges would be suspended until she completed an extra exposure as a therapeutic consequence in addition to her usual assigned daily exposure.

Fear Ladder

In the second therapy session, the therapist worked with Maddie and her mother to create a fear ladder of exposure ideas to help Maddie target her main fear that panic attacks would lead to unmanageable distress unless she left or did something to make them stop. Because the primary trigger to her anxiety cycle was the physical symptoms of panic, the therapist introduced the concept of interoceptive exposures as a means of facing fears related to physical symptoms and learning that the symptoms were not dangerous or harmful. The therapist presented a list of common panic symptoms and activities that could be done as exposures to mimic those symptoms. She further explained that by purposely practicing a symptom or two at a time, Maddie could gradually test her fears about panic symptoms becoming unmanageable and not going away. Maddie was still resistant to exposures but was less argumentative about adding fear ladder items involving practicing one or two symptoms at a time. The therapist asked Maddie to use a fear thermometer (or Subjective Units of Distress Scale) to rate the anticipated distress for each of the listed interoceptive exposures that were related to her identified symptoms (e.g., run up and down stairs for increased heart rate, breathe through a cocktail straw for difficulty breathing, and wear a coat and face a hand dryer for feeling hot and flushed). Maddie rated them all as a 100 and then a 10 after the therapist reminded her that 10 was the maximum rating.

After building a fear ladder with the interoceptive exposure items, the therapist urged Maddie and her mother to add in vivo exposures related to school and going places outside the home. Maddie cooperated with adding activities she did (p. 161) as part of previous therapy, such as going to familiar places that were not school, including a store with parents or church-related social functions. Her mother suggested items she thought would be more difficult based on Maddie’s level of refusal in avoiding them recently, including sitting in church for services and going to the movies or theater productions. Her mother added that she thought these were more difficult for Maddie in light of statements Maddie had made suggesting concern about getting out quickly from a row of seats if needed.

Of note, several times during this process, Maddie argued with her mother or therapist or simply refused to write anything down. The therapist coached Maddie’s mother in utilizing differential attention through ignoring and continuing on with the fear ladder building on her own when Maddie refused to participate balanced with responding positively to Maddie when she suggested or rated fear ladder items. With regard to brainstorming school-related in vivo exposures, Maddie became tearful, curled up in the chair, and refused to respond to her mother’s or therapist’s inquiries. The therapist verbally recognized that thinking about doing exposures is often an exposure in and of itself. She added that continuing to avoid school was not an option and that having school-related exposures as part of the fear ladder was an important step for addressing anxiety related to school. The therapist encouraged Maddie’s participation in the process because Maddie knew best what had been challenging for her in school and would make the most helpful exposure items. When Maddie continued to refuse to participate, the therapist coached Maddie’s mother through this refusal by suggesting that if Maddie chose not to participate in this task, her mother would proceed with writing down her own ideas. Maddie argued and tried to interfere with her mother’s engagement in this task, so the therapist left Maddie in the office and accompanied her mother to an adjacent room to write down a few ideas.

Together, Maddie’s mother and the therapist came up with enough ideas to progress from easier to more difficult school-related exposures—for example, looking at photos of her school, sitting outside the school building, sitting in the office, sitting in an empty classroom, and walking down the hallway. To allow for school-related exposure practice during sessions, they identified exposures that could be done in the clinic setting, such as walking down busy clinic hallways and attending a patient education class. Once back in the room with Maddie, the therapist explained that they would work on exposures from the list, generally progressing from easier to more difficult items and eventually combining interoceptive and in vivo exposures. She explained that by eventually combining physical symptoms with being in school or school-like settings, Maddie would be able to accumulate the practice she would need to learn that she could handle the experience of physical symptoms across a number of settings. Because Maddie was quite firm about her belief that she would not be able to tolerate staying in a situation with panic if she was not allowed to use relaxation techniques to manage her distress, the therapist agreed that in their initial in vivo exposure work, Maddie could use those techniques and the focus would be on staying in the situation long enough to learn that she can handle staying there. The therapist noted that the interoceptive exposures would be very important for Maddie to test her fears about (p. 162) having the symptoms. The therapist predicted that Maddie may feel differently about those symptoms and the need to use relaxation to manage them once she had accumulated experience with interoceptive exposures.

Sample Exposure

The first few exposures were very important for Maddie’s progress and started in the third therapy session. Again, Maddie argued with her mother about attending, and Maddie’s mother again relied on the therapist’s coaching to make clear that the alternative to participating in the session would be an intensive outpatient program and parents no longer calling in her school absences as excused. The therapist suggested starting with the interoceptive exposure lowest on Maddie’s fear hierarchy—running up and down stairs to increase her heart rate. Maddie was reluctant and argumentative, but knowing the alternatives, she eventually complied with running up and down stairs as long as her mother did it with her (which her mother agreed to do). The therapist guided them through the setup of the exposure, including identifying the fear that would be tested and how anxious Maddie was that it might occur. Maddie identified that she expected her anxiety would be “out of control” and she would not be able to manage it. She rated her anxiety about starting the exposure as 10 out of 10.

Following the therapist’s guidance, Maddie and her mother ran up and down one flight of stairs a couple of times. Maddie reported that her heart had started to beat faster and stronger. The therapist asked her to rate how closely her symptoms matched the symptoms she experienced during panic attacks. Maddie gave a rating of 5 out of 10, noting that the heart rate was somewhat similar to her typical panic symptoms but that she was not experiencing the other symptoms. The therapist also had her rate her anxiety about continuing, which she rated as a 9. When asked what brought her rating down, she said that after getting started things did not seem “as bad,” but she was still certain that the symptoms would get worse and spiral out of control. Third, the therapist asked Maddie to rate her physical discomfort, as opposed to anxiety, while running up and down the stairs. Maddie settled on a rating of 8. With that, the therapist recorded both the physical discomfort and the anxiety ratings on a graph, commended Maddie for her bravery in starting the exposure, and instructed Maddie and her mother to start running again. As they ran up and down the stairs, the therapist prompted Maddie to rate her physical discomfort and her anxiety about continuing. Over time, the physical discomfort ratings stayed approximately the same (a 7 or 8), and the anxiety ratings gradually decreased to a 6 after approximately 15 minutes.

Session time was coming to an end, so the therapist reviewed with Maddie what had happened during the exposure. When asked if her fear came true, Maddie stated that it was very uncomfortable but had not gotten as bad as she thought it would and had not gotten to the point of being out of control . . . yet. She attributed the lower than anticipated discomfort to symptoms not being a true panic attack, although slightly similar (i.e., 5 out of 10). She recognized that her anxiety decreased as she got used to her heart beating faster and harder, although she still felt very nervous about the possibility of feeling worse. The therapist (p. 163) highlighted the importance of practicing milder/partial panic-like symptoms to build her confidence about handling symptoms more like her usual panic attacks, commended Maddie for the completion of her first exposure, and scheduled several appointments in close succession during the next several weeks so that they could accumulate a bolus of successful exposures in hopes that she would feel more confident doing these exposures on her own between sessions.

In the following session, the therapist led Maddie through the same exposure of running up and down stairs to bring on the symptom of increased heart rate. This time, Maddie rated her discomfort similarly, but her anxiety rating peaked at a 7 and reduced to a 3 in approximately 10–15 minutes. Maddie appeared relieved as she reported that it was not as bad as the first time. She expressed some doubt regarding how well this exposure would help her with full panic attacks because they were much more uncomfortable. The therapist acknowledged that practicing this one symptom was not the same as dealing with a full panic attack, but it was one step toward doing so. The therapist suggested moving to the next item on Maddie’s physical symptom fear ladder, rapid breathing. The therapist led her through similar steps as with the first interoceptive exposure. First, she demonstrated how to hyperventilate, had Maddie and her mother practice doing so for 15 seconds, and asked Maddie to rate how closely the resulting symptoms approximated her panic attacks. Maddie rated symptoms as closer to the real experience, 8 out of 10. Her mother also commented how uncomfortable she felt, to which Maddie expressed delight that her mother could have some sense of what she had been experiencing. They then continued with hyperventilating for 30 seconds followed by a pause to rate discomfort and anxiety. They settled on 30-second intervals because Maddie was reluctant to do it for longer and experienced 8 out of 10 proximity to her usual panic symptoms with this interval. In this exposure, her anxiety rating peaked at 8 and decreased to 4. They planned in the next session to combine the two physical symptom exposures by alternating between running up and down stairs and hyperventilating for longer periods.

Course of Treatment

Maddie continued to require contingency management to engage in exposures throughout treatment, and her mother repeatedly requested therapist support enforcing the behavior plan around session attendance, completion of exposures, and school attendance. Maddie’s mother often referred to feeling as if she were “on her own” with Maddie, and despite efforts to engage Maddie’s father in treatment or at least in supporting Maddie’s mother with enforcement of the behavior plan, Maddie’s mother continued primarily on her own. With much support and fairly frequent sessions (including participation in a 5-day intensive program), Maddie made progress such that she was attending school daily with minimal visits to the counselor’s office (fewer than her usual one to three visits daily).

Maddie alternated between interoceptive exposures (gradually working her way up to the exposures identified as mimicking her worst symptoms) and in vivo exposures (gradually working her way from easier settings, such as going (p. 164) to the store, to more difficult settings, such as being in school). The therapist supported Maddie and her mother in working on a gradual return-to-school plan that followed the general progression of items from her fear ladder associated with being in school. As part of that progression, school classroom participation started with one class period daily and increased by one or two class periods every week.

During that process, Maddie’s cooperation with exposures waivered following days during which she had panic attacks at school. The therapist tried to help her frame the experiences as everyday exposure to panic while in school and opportunities to learn that she can get through those experiences. Despite the therapist’s prompting her to see that she had managed just fine, Maddie continued to verbalize her experience as “awful” because her fear of having “out of control” anxiety that had come true. The therapist acknowledged that these everyday exposures were more difficult than the planned exposures she had worked on up to that point, specifically interoceptive exposures in the safety of the office or in vivo exposures to avoided situations without inducing panic symptoms. The therapist suggested that it would be helpful to start integrating the two types of exposure, first combining the easier symptoms with easier settings and progressing to more difficult symptoms and settings. With much therapist support of her mother to utilize contingency management for engaging in these exposures, Maddie made some progress and reported feeling better about getting through panic symptoms at school.

One turning point in treatment occurred when Maddie arrived at one of the intensive program group sessions in the middle of a panic attack. She appeared unusually quiet, pale-faced, and focused on her breathing. She did not speak; her mother explained for her that she had started to panic while walking to the office from the car. Her mother expressed hope that the therapist would help. Maddie nodded when the therapist asked if she were experiencing a typical panic attack. The therapist expressed that they could turn it into an opportunity for exposure to full panic symptoms rather than selecting something else from the fear ladder as planned. Following the same procedures—by now, the therapist encouraged Maddie’s mother to lead the steps with therapist guidance as needed—Maddie rated similarity of current symptoms to her usual panic symptoms as 10 out of 10 (indicated using her fingers); her ratings for discomfort and anxiety were also 10 out of 10. The panic symptoms continued for the duration of the appointment. Maddie’s discomfort remained high (9 or 10), and her anxiety ratings declined initially to 7 out of 10 and then rose to 9 out of 10 when the therapist stated she should stay in the room in response to Maddie pointing toward the door to leave. Maddie did stay in the group room, her anxiety decreased to a 5, and she was speaking by the end of the appointment. Maddie was able to identify that although her fear of feeling uncomfortable did come true, it was unpleasant rather than dangerous and she had been able to function despite it. Her mother added that she had handled it well and differently than usual because she had managed to stay in the room rather than escaping to the bathroom as she normally would. After this point, Maddie continued to express discomfort with interoceptive exposures but appeared more confident with planned exposures.

(p. 165) As the frequency of panic attacks decreased, Maddie became excited about participating in the school play and was motivated to attend school so she could participate. Her mother expressed relief that school attendance was less of a battle. The therapist saw the family increasingly less frequently; appointments were canceled by the family, who sometimes cited conflicts with play practice as the reason for canceling or missing appointments.

After the initial treatment episode, Maddie’s trajectory was up and down. She tended to have the most difficulty after school breaks and illnesses. At those times, her mother would contact the therapist and request return calls or appointments due to difficulty getting Maddie to attend school. The therapist would review the importance of sticking with planned exposures even when Maddie had started doing well and of maintaining the contingency management plan. In addition, the therapist continued efforts to reinforce that Maddie and her mother understood the concepts and encourage greater family independence implementing them.


Maddie’s case illustrates the critical value of interoceptive exposure (IE) for panic disorder. Although Maddie had been avoiding school, and one could mistakenly focus on school as the precipitating stimulus, she did not fear school itself but, rather, experiencing unmanageable physical symptoms at school. Thus, IE was crucial to her treatment because she needed to experience physical symptoms in order to learn that these symptoms are not dangerous and that she can handle them. The in vivo exposures she completed in school, and other situations she had associated with panic symptoms, were important for her to learn that she could handle being in those settings. However, she needed to first learn that she could manage panic symptoms directly and then learn, through combining IE with the in vivo situational exposures, that she could handle panic symptoms in those various settings. Similarly, the case illustrates how multiple single exposures (i.e., running up stairs and hyperventilation) can be combined to create more realistic and challenging exposures (i.e., multiple-symptom panic attacks).

Unfortunately, as Maddie’s earlier treatment history illustrates, IE is rarely used by clinicians. For Maddie, not receiving the indicated IE had untended consequences of not only delaying improvement but also undermining her confidence in therapy. Conceptually, the well-intentioned encouragement by the school counselor to come to the office when anxious and to utilize relaxation techniques, especially without the use of IE, likely reinforced Maddie’s perception of panic symptoms as intolerable. Although her first therapist correctly identified exposure therapy as a fitting evidence-based approach for panic disorder, the focus on encouraging her to “face her fears” by attending school without use of IE left her ill-equipped to tolerate the inevitable panic attacks that occurred while doing so. It is understandable that therapists feel uncomfortable having their patients experience panic symptoms in sessions. In fact, therapists tend to overestimate the likelihood of negative outcomes, such as dropping out of therapy, decompensating, or losing consciousness, despite evidence that the approach is safe in most circumstances, and IE is actually viewed as useful by patients.

(p. 166) An additional concern is that therapists’ uncertainty about IE can negatively affect their delivery of this technique. Specifically, therapists with greater concerns about tolerability and risk associated with IE may use less intense forms of IE (e.g., allowing longer rest periods between symptom induction or teaching controlled breathing and/or cognitive reappraisal during exposures) compared to therapists with more confidence delivering IE. Unfortunately, “low-dose” IE with breathing may be less effective than prolonged and intense IE because it provides less of an opportunity to learn that panic symptoms are tolerable. In the current case, relaxation appeared to function as a form of avoidance that prevented Maddie from learning that panic was not dangerous. The power of this safety behavior led the therapist to anticipate that insisting Maddie refrain from relaxation techniques during exposures could create a significant and potentially unsurmountable barrier to her participation in therapy. Thus, use of relaxation was allowed during initial exposures and then removed to make exposures more challenging and effective. The therapist continued to reinforce the concept of safety behaviors and encouraged Maddie to refrain from relaxation during IEs she viewed as less anxiety provoking to build her confidence tolerating uncomfortable symptoms without relaxation. The potential downside to allowing or facilitating use of relaxation or other symptom management skills indefinitely runs parallel to the discussion of safety behaviors elsewhere in this book: Patients may continue to believe that they need those strategies to be “safe” from symptoms and outcomes they view as threatening.


The cases in this chapter illustrate the use of imaginal and interoceptive exposures. These forms of exposure are powerful therapeutic techniques that are the primary intervention for certain presentations of anxiety and OCD. For other presentations, imaginal and interoceptive exposures can augment the implementation of in vivo exposures. Unfortunately, these two forms of exposures are used infrequently. It has been our experience that many anxious children have symptoms amenable to imaginal and interoceptive exposures, and we encourage clinicians to add these valuable skills to their repertoire. We now turn to the final section of this book, in which we discuss common obstacles to delivering exposure therapy and where to find additional resources.