In-vivo, imaginal and interoceptive exposure

1. Introduction

Version followed: the inhibitory learning approach to exposure (Craske, Treanor, Conway, Zbozinek & Vervliet, 2014) as the organising framework, with format-specific procedures from Prolonged Exposure for PTSD (Foa, Hembree & Rothbaum, 2007 therapist guide; older Foa & Rothbaum assault version where noted), Mastery of Your Anxiety and Panic for interoceptive work (Craske & Barlow lineage, as described in Schmidt & Trakowski, 2004), Öst's one-session treatment and applied tension for specific phobias, and Wolpe's systematic desensitization (historical comparator). Where older habituation-based manuals and the inhibitory learning approach give different instructions (mainly when to stop a trial and when to move up the hierarchy), both are named and the difference is flagged.

This is not one therapy but a family of procedures that form the core of most CBT packages for anxiety, OCD and PTSD. Three channels are used: in vivo (real feared situations, objects, activities), imaginal (feared memories, images or outcomes held in mind, spoken, written or recorded), and interoceptive (deliberately provoking feared bodily sensations such as dizziness, breathlessness or a racing heart). VR and remote delivery are formats of the same procedures. [source: Wikipedia, Exposure therapy; Div 12, Exposure therapies for specific phobias]

Core idea of change: avoidance, escape and safety behaviours stop the person from discovering that the feared outcome does not happen, or is bearable when it does. Exposure arranges repeated, deliberate contact with the feared cue without those protections. In the older habituation / emotional processing account, fear falls with prolonged contact; in the current inhibitory learning account, the original fear association is not erased but a new, competing "cue = safe / outcome did not happen / I coped" memory is formed, and the work of therapy is to make that new learning strong and retrievable across settings. Fear reduction during a session is therefore no longer treated as the marker of success; violated expectations and broadened approach behaviour are. [source: Craske et al., 2014; Wikipedia, Exposure therapy (mechanisms section)]

2. Framework

Exposure is delivered in a recognisable arc whatever the channel. Session counts below come from specific protocols; for exposure embedded in other CBT packages, follow that package's schedule.

Phase A: Assessment and formulation (usually 1–2 sessions). Goals: identify feared cues (external, internal, mental), feared outcomes, avoidance, escape and safety behaviours (overt and subtle), and medical or risk issues that change the plan. For panic, a standardised symptom-induction assessment is done in session (see 4.15). Move on when you can state, for each target, what the client fears will happen, what they do to prevent it, and which channel(s) will test it. [source: Craske et al., 2014; Schmidt & Trakowski, 2004]

Phase B: Psychoeducation, rationale and consent (usually 1 session, often merged with A). Goals: client understands the avoidance-maintains-fear model, that exposure will be uncomfortable by design, that they keep the right to stop, and agrees to a first set of targets. Hierarchy (fear ladder) built here. Move on when the client can explain the rationale back and has agreed a first exposure. [source: PE protocol outline (UW); Craske et al., 2014] [synthesis: explicit teach-back as the criterion]

Phase C: Active exposure (the bulk of treatment). In-session therapist-guided exposure plus daily between-session practice.

Specific phobia: either one massed session of up to about 3 hours (Öst's one-session treatment), or roughly 3–8 sessions of 60–90 minutes. [source: Div 12; Zlomke & Davis, 2008 abstract]
PTSD (Prolonged Exposure): about 8–15 sessions, usually weekly or twice weekly. In the protocol outline: session 1 rationale, trauma interview and breathing; session 2 common reactions, in vivo hierarchy; session 3 first imaginal exposure; middle sessions imaginal plus processing plus in vivo review, with hot-spot work introduced around sessions 6–7 in the 2007 guide's training outline (session 4 onward in the older outline); final session review and relapse prevention. Typical session length is 90 minutes in the 2007 guide [uncertain: session length not stated in the sources; 90 minutes is from the published therapist guide as commonly taught]. [source: PE protocol outline (UW); CDP PE course page]
Panic disorder (MAP lineage): interoceptive assessment around mid-treatment (session 5 in the Schmidt & Trakowski group programme), then graded interoceptive exposure in session plus daily home practice, then naturalistic interoceptive and in vivo exposure. [source: Schmidt & Trakowski, 2004]
OCD: exposure with response prevention, combining in vivo and imaginal (script) exposure; schedule set by the ERP package used. [source: Wikipedia, Exposure therapy; IOCDF Scripting for Success]

Criteria for moving up a hierarchy step:

Habituation-based manuals (older PE outline, many patient leaflets): stay until fear drops substantially (often stated as at least 50% from peak) or for a fixed 30–45 minutes, and move up when an item produces low distress or the client feels confident. [source: PE protocol outline (UW); Leicestershire NHS needle leaflet; IOCDF]
Inhibitory learning (followed here): trials last as long as needed to test the specific prediction ("until the thing you feared would happen has had a fair chance to happen"), not until fear falls; move on when the feared outcome has been clearly disconfirmed and the expectancy rating has fallen, and items may be taken out of order rather than strictly bottom-up. Start with moderately difficult items to secure engagement. [source: Craske et al., 2014]

Phase D: Consolidation, relapse prevention and ending (1–2 sessions). Goals: vary contexts, remove remaining safety signals, practise alone and in unfamiliar settings, plan for return of fear (lapse versus relapse), and set a self-directed maintenance schedule. Retrieval cues are introduced here rather than early. In PE, a symptom measure is re-administered near the end to decide whether to stop or extend. End when the main targets are approached without safety behaviours in several contexts and the client can design their own next exposures. [source: Craske et al., 2014; PE protocol outline (UW)] [synthesis: "can design own exposures" as an ending criterion]

Format: individual is standard; group delivery is documented for panic (interoceptive assessment in a group, Schmidt & Trakowski, 2004) and for phobia. Settings range from the office to the field (shops, transport, heights), VR labs and remote delivery. [source: Div 12; Schmidt & Trakowski, 2004]

3. Guiding principles

Avoidance is the target. Practical meaning: every plan is built around the specific things the client avoids or escapes, not around "anxiety" in general. [source: Div 12; Wikipedia]
Test a specific feared outcome. Practical meaning: before each trial, name the concrete catastrophe (e.g. "I will faint", "they will laugh at me") and rate its likelihood 0–100; "I'll get anxious" is not enough. [source: Craske et al., 2014]
Design trials to violate expectancies, not to reduce fear. Practical meaning: set duration, intensity or repetitions so that the prediction gets a fair test; a trial can end with fear still high. [source: Craske et al., 2014] Habituation-based manuals instead end when fear has dropped; know which rule your protocol uses. [source: PE protocol outline (UW)]
Hold cognitive work until after the trial. Practical meaning: do not reassure or dispute the catastrophe beforehand (it lowers the expectancy you are testing); do reflection and reappraisal in post-exposure questioning. [source: Craske et al., 2014]
Drop safety behaviours and safety signals. Practical meaning: list them and remove them, immediately if the client is willing, gradually only if needed to keep them in treatment. [source: Craske et al., 2014]
Distraction is a safety behaviour. Practical meaning: no phones, earphones, counting or mental escape during trials; keep attention on the feared cue. [source: Craske et al., 2014]
Vary it. Practical meaning: vary stimuli, durations, intensities, places, times, company; do not let the client learn safety only in your office. [source: Craske et al., 2014]
Repetition and between-session practice carry the change. Practical meaning: assign daily practice and treat homework review as the first item of each session. [source: Schmidt & Trakowski, 2004; PE protocol outline (UW); Wikipedia (adherence predicts outcome)]
Collaborative, never coercive. Practical meaning: the client agrees each step and can stop; the therapist encourages, models and negotiates but does not trick or force. [source: Wikipedia (graded exposure: patients can stop at any time)] [synthesis: framing as a consent principle]
Therapist goes first when useful. Practical meaning: model the step (touch the object, do the spin) and then guide the client through it (participant modelling). [source: Div 12; Zlomke & Davis, 2008]
Real danger is not an exposure target. Practical meaning: exposures are to situations that are objectively safe or of normal everyday risk; never ask someone to stay in actual danger (e.g. an abusive relationship, unsafe driving). [source: PE protocol outline (UW): "safe but anxiety-provoking"] [synthesis: generalisation]
Screen the body before provoking it. Practical meaning: check heart, lung, seizure, pregnancy, blood-pressure and other conditions before interoceptive work and get medical advice where relevant. [source: ADAA, Gupta & Bishop, 2023]
Therapist anxiety about exposure is a treatment risk. Practical meaning: notice urges to shorten, water down or rescue; check them against the rationale before acting. [synthesis] [uncertain: therapist-belief research (e.g. Deacon and colleagues)]

4. Intervention inventory

Grouped as A. preparation (4.1–4.5), B. in vivo (4.6–4.16), C. imaginal (4.17–4.22), D. interoceptive (4.23–4.26), E. adjuncts, formats and consolidation (4.27–4.32). All example language is illustrative unless quoted and cited.

A. Preparation

4.1 Functional assessment of fear, avoidance and safety behaviours

Purpose / when: First sessions, and again whenever progress stalls. Maps what to expose to and what to stop doing. [source: Craske et al., 2014]
Steps: (1) List triggers in three channels: external (places, objects, people), internal (sensations), mental (images, memories, intrusive thoughts). (2) For each, ask what the client predicts will happen, in concrete terms. (3) List avoidance (not going), escape (leaving early) and safety behaviours (carrying medication, phone, water; sitting near exits; holding on; distraction; reassurance-seeking; checking pulse; company of a "safe" person). (4) Ask about subtle ones: "What do you do so that it doesn't get worse?" (5) Record a short formulation: cue → prediction → protection → prediction never tested.
Example language (illustrative): "When you're in the supermarket queue and your heart starts racing, what's the worst thing you think could happen right then? And what do you do to stop that happening?"
Watch for: Clients often report "anxiety" as the feared outcome; push for the specific catastrophe. Safety behaviours are often invisible to the client; ask a partner or observe during the first exposure. Working: client can name predictions and protections for each target.

4.2 Psychoeducation and rationale; informed consent

Purpose / when: Before any exposure. Builds willingness and is the consent step. [source: PE protocol outline (UW); Wikipedia; Craske et al., 2014]
Steps: (1) Draw the avoidance cycle with the client's own example. (2) Explain that exposure works by approaching the feared thing without protections so the prediction can be tested. (3) State plainly that sessions will be uncomfortable on purpose and that discomfort is not a sign of harm. (4) Describe the channels to be used and any physical demands (e.g. spinning, overbreathing). (5) Name the right to stop or slow down at any time, and agree that you will negotiate rather than abandon the step. (6) Discuss risks: short-term rise in distress, possible temporary rise in symptoms (in PTSD, intrusions may briefly increase), dropout. (7) Ask for teach-back. (8) Document consent. For trauma work, give the common reactions handout (PE session 2). [source: PE protocol outline (UW)] [synthesis: teach-back and explicit risk statement]
Example language (illustrative): "Every time you leave the shop when the dizziness starts, your brain files that as 'I escaped just in time.' It never gets to find out what would have happened if you'd stayed. That's what we're going to find out, step by step, and you'll be in charge of the pace."
Watch for: Agreement without understanding; ask the client to explain why staying matters. Working: the client can explain why leaving early keeps the fear going.

4.3 Exposure hierarchy (fear ladder) with SUDS

Purpose / when: Phase B. Gives a menu of graded targets. [source: Div 12; PE protocol outline (UW); Leicestershire NHS leaflet]
Steps: (1) Generate 10–20 situations, images or sensations the client avoids or endures with dread, ranging from mild to the most feared. (2) Rate each on SUDS (Subjective Units of Distress, 0–100; Wolpe's scale) for expected distress if done without safety behaviours. Anchor the scale with the client's own examples (0 = calm at home; 100 = worst ever; in PE, distress during the trauma). (3) Add variants that change difficulty: duration, distance, alone versus accompanied, time of day, crowding. (4) Order items. (5) Choose a starting point: PE and many manuals start around 40–60 SUDS; the inhibitory learning approach recommends moderately difficult items and allows taking items out of order later. [source: PE protocol outline (UW); Craske et al., 2014]
Example language (illustrative): "If 0 is sitting on your sofa and 100 is the worst panic you've ever had, where would standing in the middle of a busy train carriage for ten minutes, with no water bottle, sit?"
Watch for: Items that are all "100" (break them down); items that secretly include safety behaviours ("go to the shop with my husband" — list the without-husband version separately). The hierarchy is a working document; revise it.

4.4 Expectancy identification and rating

Purpose / when: Before every exposure trial (inhibitory learning approach). Sets up the prediction to be disconfirmed. [source: Craske et al., 2014]
Steps: (1) Ask what the client fears will happen in this specific trial. (2) Make it observable and time-bound ("I will faint within 2 minutes", "the cashier will look at me with disgust"). (3) Rate likelihood 0–100. (4) Optionally rate how bad it would be and how well they could cope. (5) Design the trial so the prediction gets a fair test (e.g. if the fear is collapse after 30 seconds of dizziness, spin for longer than 30 seconds; Craske et al.'s panic case used 60 seconds). (6) Do not reassure or dispute now. [source: Craske et al., 2014]
Example language (illustrative): "What exactly do you think will happen if you stay in the lift for five minutes? How likely, 0 to 100? How will we know if it happened?"
Watch for: Predictions that cannot be disconfirmed ("I might go mad someday"): reframe to something testable now or note that the target is tolerating uncertainty (OCD). Older PE homework forms also ask the client to rate the worst outcome and its likelihood before practice, but follow it with evidence for and against, which the inhibitory approach defers to afterwards. [source: PE protocol outline (UW); Craske et al., 2014]

4.5 Medical and risk screening before exposure

Purpose / when: Before interoceptive exposure, intensive in vivo work, blood-injury work, or trauma-focused imaginal exposure.
Steps: (1) Ask about heart conditions, low or high blood pressure, asthma or other lung disease, epilepsy or seizures, pregnancy, and any other relevant condition; exercises may not suit people with these and should not be painful. [source: ADAA, Gupta & Bishop, 2023] (2) Ask about neck, back, inner-ear or balance problems before spinning, head-shaking or head-between-legs exercises, and history of fainting (blood-injury phobia). [synthesis] (3) If any are present, get medical advice and either substitute a gentler exercise (e.g. stair climbing for running in place; seated swivel chair rather than standing spin) or skip the channel. Schmidt & Trakowski describe substitutions for physical restriction. [source: Schmidt & Trakowski, 2004] (4) Assess suicide risk with your service's standard structured assessment; acute risk, current crisis or ongoing actual danger (e.g. still living with the perpetrator) are reasons to stabilise or safety-plan first. [synthesis, consistent with standard practice] (5) Check substance use and dissociation, which may block engagement. [synthesis]
Example language (illustrative): "Some of these exercises make your heart race or make you breathless. Before we try them, I need to check a few things about your physical health, and if there's any doubt we'll ask your GP first."
Watch for: Clients using "medical risk" as avoidance; get a clear medical answer rather than accepting or dismissing the worry.

B. In vivo exposure

4.6 Graded in vivo exposure

Purpose / when: First-line for specific phobias, agoraphobia, social anxiety, OCD (with response prevention) and PTSD-related avoidance. Strongest support for specific phobia. [source: Div 12]
Steps: (1) Choose an item from the hierarchy. (2) Set the expectancy (4.4). (3) List the safety behaviours to drop for this trial. (4) Enter the situation; client keeps attention on the cue. (5) Therapist prompts focus, notes SUDS at set intervals (e.g. every 5–10 minutes) and blocks escape and safety behaviours by encouragement, not force. (6) Duration: inhibitory rule — long enough to test the prediction; habituation rule — 30–45 minutes or until SUDS drops by at least half (PE outline). (7) Repeat in session where possible; vary it (4.12). (8) Post-exposure questioning (4.15). (9) Assign daily home practice of the same or adjacent item. [source: Craske et al., 2014; PE protocol outline (UW)]
Example language (illustrative): "Stay with it. Notice the feeling in your chest, and notice the dog. You don't need to make the anxiety go down; just let it be there."
Watch for: Leaving early, "white-knuckling" with mental distraction, the client doing the step only with you present. Working: approach behaviour widens, expectancy ratings fall across trials, client starts proposing harder steps.

4.7 Flooding and intensive (massed) exposure

Purpose / when: Starting at or near the top of the hierarchy, or massing many hours of exposure into a short period. Used when the client prefers speed and is willing; some approaches (e.g. implosion) start with highly anxiety-provoking stimuli. [source: Div 12; Wikipedia]
Steps: (1) Thorough consent: describe expected intensity. (2) Screen as 4.5. (3) Plan a long block (often 2–3 hours) so there is time to stay until the prediction is clearly tested. (4) Begin with the high-SUDS item; therapist stays present, models and encourages. (5) Do not end the block at the point of peak fear-driven escape if it can be avoided; negotiate a smaller step instead. (6) Post-exposure questioning and a home plan. [source: Div 12; Wikipedia] [synthesis: steps 3, 5]
Example language (illustrative): "We've set aside the whole afternoon so that we can stay as long as it takes. If it gets too much, we'll step back one rung, not out the door."
Watch for: Dropout and escape at peak, which can strengthen the fear; graded exposure is the default for most clients. [synthesis] [uncertain: no current guideline cited that sets criteria for flooding versus graded]

4.8 Participant modelling / guided mastery

Purpose / when: Specific phobias, agoraphobia, any step the client cannot yet do alone. Called participant modelling or guided mastery when the therapist models each step. [source: Div 12; Williams, 1990 (cited by Div 12)]
Steps: (1) Therapist performs the step while the client watches (e.g. picks up the spider in a cup, lets it walk on own hand), describing what they are doing calmly and factually. (2) Client does a partial version with therapist help (therapist's hand near or on theirs, therapist holding the container). (3) Fade help: therapist steps back, then out of reach, then out of sight. (4) Client repeats alone, then in a different setting. [source: Div 12; Zlomke & Davis, 2008] [synthesis: exact fading sequence]
Example language (illustrative): "Watch what I do. I'll let it walk across my palm. Now put your hand next to mine, just touching my fingers."
Watch for: Therapist presence becoming a safety signal; plan to fade it and to test alone. Working: client can do the step without the therapist.

4.9 One-session treatment (Öst) for specific phobia

Purpose / when: Specific phobias (animals, injections, heights, etc.) in adults and children; one session of up to about 3 hours, usually preceded by an assessment and followed by self-directed maintenance. [source: Zlomke & Davis, 2008 abstract; Div 12; ACAMH OST infographic]
Steps (structure; wording here is my own): (1) Assessment session: map the fear, identify catastrophic beliefs about the phobic object, build the hierarchy, and get commitment to the massed session. [uncertain: details of the preparation session from Öst's original 1989 description] (2) Massed session: work up the hierarchy as a chain of behavioural experiments, each testing a specific catastrophic belief (e.g. "the spider will run up my arm"). (3) Therapist models each step, then client does it (4.8). (4) Cognitive challenge after each step: what was predicted, what happened. (5) Reinforce each approach. (6) Continue until fear and belief in catastrophe are substantially reduced and the top item is achieved, within the session. (7) Agree continued self-directed exposure afterwards. [source: Zlomke & Davis, 2008 abstract (four components: exposure, participant modelling, cognitive challenges, reinforcement)]
Example language (illustrative): "You said you're 90% sure it will jump at you if I take the lid off. Let's take the lid off and watch for a full minute."
Watch for: Fatigue near the end; keep breaks short. Working: client reaches a far higher step than predicted in the same session.

4.10 Applied tension for blood-injection-injury (BII) phobia

Purpose / when: BII phobia with a history of fainting (a vasovagal blood-pressure drop). Counteracts the drop so that exposure can proceed safely. [source: Div 12; Öst & Sterner, 1987 (cited by Div 12)]
Steps: (1) Teach seated. Tense the arm, trunk and leg muscles together for about 10–15 seconds, until the client feels warmth rising in the face. (2) Release to normal sitting (not deep relaxation) for about 20–30 seconds. (3) Repeat, five cycles in total. (4) Home practice: several times daily (the NHS leaflet says about three times a day for a week) before exposure. (5) Then graded exposure to blood and needles (pictures, videos, medical equipment, observing a blood draw, own finger-prick or injection), using tension at the first sign of light-headedness. (6) Client sits or reclines for exposure items with fainting risk. [source: Leicestershire NHS needle-phobia leaflet] [uncertain: the leaflet does not cite Öst; timings match the commonly cited Öst procedure but the original paper is not drawn on]
Example language (illustrative): "Squeeze your arms, chest and legs together, hold it, notice the warmth come into your face... and let go, just back to normal sitting."
Watch for: Headaches (leave out face and head muscles); caution for any body part with a health problem. Pallor, sweating, tunnel vision = apply tension and lower the head/body. [source: Leicestershire NHS leaflet] Do not use relaxation alone with fainters. [synthesis] Working: client completes exposure items without fainting and fear falls.

4.11 Safety-behaviour identification and response prevention

Purpose / when: Throughout. In OCD this is the response prevention part of ERP: no rituals during or between sessions. In other anxiety problems it means dropping protective behaviours and safety signals (people, phones, medication carried, food, drink, distraction). [source: Wikipedia (ERP); Craske et al., 2014]
Steps: (1) Use the list from 4.1. (2) For each trial agree which are dropped. (3) If the client is willing, remove all at once (preferred in inhibitory learning); otherwise fade gradually to reduce dropout. (4) Check after each trial: "Was there anything you did to keep yourself safe?" (5) Watch for substitution (one safety behaviour replaced by another, e.g. mental reviewing instead of checking). (6) For OCD, agree explicit rules for rituals and reassurance, and a plan for urges (notice, name, don't act). [source: Craske et al., 2014; Wikipedia; IOCDF Scripting for Success]
Example language (illustrative): "This time, leave the pills at home. The question we're testing is whether you're safe without them."
Watch for: Covert safety behaviours (praying, counting, telling oneself "it's fine", checking the exit). Evidence on judicious use of safety behaviours is mixed; if a client can only start with one, plan its removal. [source: Craske et al., 2014]

4.12 Variability and multiple contexts

Purpose / when: From early in Phase C, increasingly in Phase D. Makes new learning generalise and reduces return of fear. [source: Craske et al., 2014]
Steps: (1) Vary the stimulus (different dogs, sizes, colours), duration, intensity and spacing between sessions (progressively longer gaps). (2) Take hierarchy items in a non-linear order once engaged. (3) Practise in different places, times of day, alone and with others, familiar and unfamiliar settings. (4) Apply to interoceptive and imaginal work too. [source: Craske et al., 2014]
Example language (illustrative): "You've done the lift at work. This week let's do lifts in three buildings you've never been in, at different times of day."
Watch for: Variable exposure produces higher, non-declining arousal; that is expected and not a sign of failure. Evidence for multiple-context benefit is inconsistent. [source: Craske et al., 2014]

4.13 Deepened extinction (combining cues)

Purpose / when: After two or more cues have each been practised alone. [source: Craske et al., 2014]
Steps: (1) Exposure to cue A alone, then cue B alone, until each is approached. (2) Combine A and B in one trial (e.g. two spiders together; a crowded mall after a caffeinated drink; spinning then exercise). (3) Both cues must predict the same feared outcome. [source: Craske et al., 2014]
Example language (illustrative): "You've done the spinning, and you've done the crowded shop. Today, let's spin first and then walk straight into the crowd."
Watch for: Combined trial too difficult — shorten rather than abandon.

4.14 Affect labelling during exposure

Purpose / when: During in vivo (and other) exposure, as an alternative to suppression or reappraisal. [source: Craske et al., 2014]
Steps: (1) Ask the client to describe the cue and their emotional response in simple words while facing it. (2) No attempt to change or dispute the feeling. [source: Craske et al., 2014]
Example language (illustrative): "Just say what you see and what you feel: 'There's a big hairy spider, and I feel scared and disgusted.'"
Watch for: Labelling turning into reassurance ("I'm scared but it's fine") — redirect to plain description.

4.15 Post-exposure consolidation questioning

Purpose / when: Immediately after every trial. Consolidates what was learned. In the inhibitory approach, this is where cognitive work goes. [source: Craske et al., 2014]
Steps: Ask: (1) What did you fear would happen? (2) What actually happened? (3) How do you know? (4) What did you learn? (5) How surprised are you? (6) Re-rate the likelihood of the feared outcome. In PE (imaginal), the processing discussion asks what came up, whether it was easier or harder than expected, and how the client feels now. [source: Craske et al., 2014; PE protocol outline (UW)]
Example language: Short verbatim questions from Craske et al. (2014): "What did you fear would happen?" and "What happened?"; follow with (illustrative) "So what does that tell you about the lift?"
Watch for: Discounting ("It didn't happen because you were there") — that identifies a safety signal to remove next time. Avoid replaying negative moments after social exposures; redirect to what was learned. [source: Craske et al., 2014]

4.16 Homework and self-directed exposure

Purpose / when: Every session. Adherence to homework predicts outcome. [source: Wikipedia; Schmidt & Trakowski, 2004]
Steps: (1) Agree specific items, frequency (typically daily), duration and which safety behaviours to drop. (2) Client writes the prediction beforehand and the outcome afterwards on a practice record (item, date, time, peak SUDS, prediction rating before and after). (3) Review at the start of next session. (4) Troubleshoot barriers. [source: PE protocol outline (UW); Schmidt & Trakowski, 2004]
Example language (illustrative): "Let's be specific: which day, what time, which shop, and how long will you stay?"
Watch for: Partial completion, doing it only with a companion. See section 5 for non-adherence.

C. Imaginal exposure

4.17 Imaginal exposure to a trauma memory (Prolonged Exposure)

Purpose / when: PTSD; from PE session 3 onward, every session. Repeated, emotionally engaged revisiting of the index trauma memory so it can be processed and stops being avoided. [source: PE protocol outline (UW); CDP PE course page; Wikipedia]
Preconditions: Rationale given (4.2), in vivo work started, risk assessed, client not in ongoing danger. [synthesis: standard practice] [uncertain: the 2007 guide's full exclusion list]
Steps: (1) Explain the rationale for revisiting the memory: avoiding it keeps it unprocessed and frightening. (2) Client closes eyes and recounts the trauma aloud, in the present tense and first person, as vividly as possible, including thoughts, feelings and sensations. (3) Therapist takes SUDS periodically (the older outline says about every 10 minutes; ask briefly without breaking the narrative) and gives brief supportive prompts. (4) When the narrative ends, the client starts again from the beginning; continue for the planned time (up to about 60 minutes in the older outline; 30–45 minutes is the commonly taught figure for the 2007 guide). (5) Record the imaginal exposure for homework. (6) Close: eyes open, a few breaths, then processing (4.18). [source: PE protocol outline (UW)] [uncertain: the 30–45 minute figure and SUDS every 5 minutes in the 2007 guide are from training convention]
Example language (illustrative): Prompts kept short: "What are you seeing now?" "What are you feeling in your body?" "Stay with it, you're doing well." "What happens next?"
Watch for: Under-engagement (flat, fast, past-tense, factual narrative; low SUDS): encourage eyes closed, present tense, more sensory and emotional detail, slower pace. Over-engagement (dissociation, losing contact with the room, overwhelming distress): ask the client to open eyes, use past tense, and increase therapist talk and grounding to the present. [uncertain: under/over-engagement adjustments are standard PE training content] Working: SUDS during imaginal exposure decline across sessions, narrative becomes more coherent, new details and perspectives emerge in processing, intrusions and avoidance decline.

4.18 Processing after imaginal exposure

Purpose / when: Immediately after each imaginal exposure (about 15–20 minutes in usual practice [uncertain]). Helps the client integrate what came up. [source: PE protocol outline (UW); CDP PE course page]
Steps: (1) Open questions: how was that, what came up, any new details, easier or harder than expected, how do you feel now. (2) Follow the client's lead toward meanings (self-blame, guilt, danger, incompetence). (3) Use questions rather than lectures to help the client notice what the memory shows (e.g. what they could and could not have known at the time). (4) Validate. (5) Link to in vivo targets. [source: PE protocol outline (UW)] [synthesis: steps 2–3]
Example language (illustrative): "You said 'I should have fought back' again today. When you were in it just now, what was happening in your body at that moment?"
Watch for: Processing turning into debate; keep it Socratic and brief.

4.19 Hot-spot work

Purpose / when: Middle-to-late PE sessions (sessions 6–7 in the CDP outline of the 2007 guide; from session 4 in the older outline), once the full narrative has been repeated several times. [source: CDP PE course page; PE protocol outline (UW)]
Steps: (1) Identify with the client the moments of the memory that are most distressing now (high SUDS, avoided or skipped in the narrative). (2) In imaginal exposure, instead of the whole story, repeat one hot spot many times, slowly, with full detail. (3) Move to the next hot spot when its distress has fallen. (4) Return to the full narrative near the end of treatment. [source: CDP PE course page (hot spots introduced)] [uncertain: identification and repetition procedure from standard PE training]
Example language (illustrative): "Today, rather than telling the whole story, let's go back to the moment the door opened, and stay just with that, as slowly as you can."
Watch for: Client rushing past the hot spot; slow them down.

4.20 Recorded imaginal exposure as homework

Purpose / when: After every imaginal exposure session in PE. [source: PE protocol outline (UW)]
Steps: (1) Record the in-session imaginal exposure. (2) Client listens daily, ideally at a set time in a private place, and logs SUDS. (3) In the older outline the client also listens to the whole session recording once. (4) Review the log next session. [source: PE protocol outline (UW)]
Example language (illustrative): "Listen once a day, all the way through, with your eyes closed as if you were back here. Note your distress at the start, peak and end."
Watch for: Listening while distracted (driving, chores) or skipping; ask how and where they listened.

4.21 Imaginal exposure scripts (OCD, worry, feared outcomes)

Purpose / when: OCD and other fears where the feared outcome is a thought, image or future catastrophe that cannot ethically or practically be done in vivo; also as a step toward in vivo exposure, or paired with it. [source: IOCDF Scripting for Success; Wikipedia]
Steps: (1) Identify the trigger, the intrusive thought or image, the feared consequence, and what it would mean about the client. (2) Write the script together, in first person and present tense, with sensory detail (what is seen, heard, felt in the body and emotionally). (3) Grade it: early scripts vaguer and lower-intensity (e.g. becoming ill), later ones closer to the worst feared outcome. (4) Use uncertain wording (the event may happen) and include no reassurance. (5) A suggested sequence: trigger, intrusion, emotional and bodily reaction, doubting thoughts, urge to ritualise without doing it, what it says about me, core fear; end on an uncertain or bad outcome and accepting the risk. (6) Read aloud or record; client listens with full attention, without mental or physical neutralising. (7) Repeat regularly; pair with in vivo items where suitable (e.g. listening while holding a kitchen knife). [source: IOCDF Scripting for Success] (8) Stopping rule: IOCDF slides use a 50% drop in anxiety; under the inhibitory approach use a fixed duration or number of repetitions agreed in advance. [source: IOCDF; Craske et al., 2014]
Example language (illustrative): "Write it as if it's happening now, in your words: 'I'm standing at the stove and the thought comes that I left the gas on...'"
Watch for: Script does not raise anxiety (missing core fear, depression limiting focus, fear that writing will increase obsessions); covert neutralising during listening (self-reassurance, arguing with the thought); no generalisation (add in vivo). Key client messages: thinking about a feared event does not make it happen; deliberately raising anxiety is not dangerous. [source: IOCDF Scripting for Success]
Note: Written exposure therapy (writing a trauma account; Sloan and Marx) is a related brief PTSD protocol. [source: Wikipedia] [uncertain: protocol not detailed here]

4.22 Systematic desensitization (Wolpe)

Purpose / when: Historical origin of graded exposure; pairs imagined (or real) hierarchy items with relaxation. Takes longer than in vivo exposure and mainly reduces subjective anxiety rather than avoidance; not recommended first-line where in vivo exposure is acceptable. Use only when in vivo and standard imaginal exposure are not feasible or acceptable. [source: Div 12]
Steps (Wolpe's structure, own wording): (1) Train progressive muscle relaxation over several sessions. (2) Build a hierarchy with SUDS. (3) With the client relaxed, describe the lowest item for a short time; the client signals (e.g. lifts a finger) if anxiety appears. (4) Withdraw the scene on signal or after the set time, re-establish relaxation, repeat. (5) Move up only when an item produces no anxiety on repeated presentations. [uncertain: based on Wolpe (1958, 1990); exact presentation times not verified]
Example language (illustrative): "Keep relaxing. Now picture yourself standing at the bottom of the escalator... If you feel any tension, raise your finger."
Watch for: Relaxation acting as a safety behaviour; inhibitory learning argues against using strategies that reduce arousal during exposure. [source: Craske et al., 2014 (safety signals); synthesis applying it to SD]

D. Interoceptive exposure

4.23 Symptom induction assessment

Purpose / when: Panic disorder (and other presentations where bodily sensations are feared, e.g. health anxiety [synthesis]); in the MAP lineage, done in session before interoceptive practice (session 5 in Schmidt & Trakowski's group programme). After medical screening (4.5). [source: Schmidt & Trakowski, 2004]
Steps: (1) Therapist demonstrates each exercise, then client does it. (2) Standard set used by Schmidt & Trakowski (durations from their table): shaking head side to side (about 30 s); head between knees then sitting up (30 s); vigorous running on the spot (60 s; stairs as substitute); breath holding; gag-reflex induction (brief); spinning standing with a spotter or in a swivel chair (60 s); push-ups or holding the up position; rapid deep mouth breathing / overbreathing (up to 120 s in their programme); breathing through a very narrow straw with nose pinched (up to 120 s). (3) Several minutes between exercises. (4) After each, client describes sensations, then rates 0–10: intensity of sensations, anxiety, and similarity to their panic. Keep sensation and anxiety ratings separate. (5) If the client does it half-heartedly, repeat, extend or substitute. (6) Advanced options for specific fears: heat (hot room, warm clothing, sauna), staring at a mirror or a spot on the wall (derealisation), caffeinated drinks, tight clothing around neck or chest; CO₂ inhalation and drug-based challenges are laboratory procedures, not office tools. [source: Schmidt & Trakowski, 2004; Kaiser Permanente interoceptive handout]
Example language (illustrative): "I'll do it first so you can see. Then you spin for a full minute. Afterwards, tell me what you noticed, then rate how strong the feelings were, how anxious you got, and how much like a panic attack it felt."
Watch for: High similarity with low anxiety (safety cues in the room may be dampening fear; repeat at home). Exercises that cause pain should stop. [source: Schmidt & Trakowski, 2004; ADAA]

4.24 Graded interoceptive exposure practice

Purpose / when: Panic disorder after assessment; dizziness, breathlessness and cardiac sensations are most commonly feared, and spinning, straw breathing and overbreathing usually most intense. [source: Schmidt & Trakowski, 2004]
Steps: (1) Order exercises that produced fear into a hierarchy, least to most anxiety. (2) Set the expectancy before each trial (e.g. "if I'm dizzy for 30 seconds I'll collapse"). (3) Do the exercise long enough to test it; to start at moderate anxiety, an exercise can be shortened (e.g. 20 s of overbreathing). (4) Ask the client to keep going past the point of first noticing the sensations and to stay with them afterwards without coping manoeuvres (no sitting down fast, sipping water, slow breathing to stop it). (5) Repeat several trials per session. (6) Record exercise, duration, sensation intensity, anxiety. (7) Habituation rule (Schmidt & Trakowski): repeat until anxiety is as low as possible and move on when the first trial produces strong sensations but little fear. Inhibitory rule: move on when the prediction is clearly disconfirmed; fear reduction within session is de-emphasised. (8) Home practice about daily, multiple trials each time. [source: Schmidt & Trakowski, 2004; Craske et al., 2014]
Example language (illustrative): "You said 85% sure you'd faint after 30 seconds of dizziness. Let's spin for a full minute and then stand still and see."
Watch for: Cheating (doing it gently), stopping as soon as sensations start, using breathing to suppress sensations. Working: expectancy ratings fall; client starts doing exercises without a spotter or therapist present; fear of sensations in daily life drops.

4.25 Naturalistic interoceptive exposure

Purpose / when: After office exercises; brings feared sensations into everyday activities that were avoided. [source: Craske et al., 2014; Kaiser Permanente handout]
Steps: (1) List avoided activities that produce the feared sensations: exercise and climbing stairs, hot showers, saunas or hot cars, hot drinks in warm clothing, caffeinated drinks (where medically appropriate), eating quickly or until full, tight collars or scarves, horror or action films, fairground rides. (2) Grade and schedule them, with the expectancy for each. (3) Drop associated safety behaviours (checking pulse, carrying water). [source: Kaiser Permanente handout; Craske et al., 2014] [synthesis: films, rides]
Example language (illustrative): "You've stopped running for the bus because your heart pounds. This week: run for it, and notice what your heart does afterwards."
Watch for: Clients doing the activity but resting immediately after or checking pulse; include the after-period in the exposure.

4.26 Combined interoceptive and in vivo exposure

Purpose / when: Agoraphobia and panic where sensations and places are feared together; also a form of deepened extinction. [source: Craske et al., 2014]
Steps: (1) After each has been practised separately, induce sensations then enter the situation (e.g. spin or overbreathe, then go into the crowded shop; a caffeinated drink before a mall exposure). (2) Same feared outcome predicted for both. (3) Variation across places and times. [source: Craske et al., 2014]
Example language (illustrative): "Run up the station stairs, and then get straight on the train while your heart's still pumping."
Watch for: Overload in early sessions; start with combined items of moderate difficulty.

E. Adjuncts, formats and consolidation

4.27 Occasional reinforced extinction (letting the feared outcome happen, safely)

Purpose / when: Later in treatment, where the feared outcome is harmless if it occurs (social rejection, embarrassment, a panic attack). Linked in the lab to less reacquisition of fear. [source: Craske et al., 2014]
Steps: (1) With consent, design an exposure in which the mildly aversive outcome is deliberately brought about (e.g. a deliberate social blunder or "shame attack"; for panic, staying in a situation through a full panic). (2) Post-exposure questioning focused on coping and on the outcome being bearable. (3) Never in dangerous situations. [source: Craske et al., 2014 (ethically prohibitive in dangerous environments; human evidence still developing)]
Example language (illustrative): "This time the aim is to be turned down. Ask three shops for something they obviously don't sell, and see what being turned down is actually like."
Watch for: Clients for whom the outcome would be genuinely harmful (job loss, safety) — do not use.

4.28 Breathing retraining (as used in PE) and its limits

Purpose / when: PE introduces slow calm breathing in session 1 as a general skill for daily tension, practised about 10 minutes three times a day in the older outline. It is not part of the exposure itself. [source: PE protocol outline (UW); CDP PE course page]
Steps: (1) Teach slow, normal-depth breathing with a long, slow exhale and a calming word on the out-breath. (2) Practise daily outside exposure. [uncertain: the calming-word detail is from PE training convention] (3) Do not use during exposure trials or interoceptive exercises; in the inhibitory learning approach, strategies used to prevent or stop sensations act as safety behaviours. [source: Craske et al., 2014 (safety behaviours); synthesis applying it here]
Example language (illustrative): "This is for everyday tension, not for getting out of the exercises we do here."
Watch for: Client using breathing to abort exposures; name it and drop it for exposure trials.

4.29 Virtual reality exposure

Purpose / when: Where in vivo access is impractical (flying, heights) or as a step before in vivo; best support for flying and height phobias; also VR for PTSD in military samples. [source: Div 12; Wikipedia]
Steps: (1) Same preparation as in vivo (4.1–4.5), plus screening for motion (cyber) sickness and seizure history. [synthesis] (2) Select scenario and graded parameters (height, turbulence, crowd size). (3) Set expectancy, run the scenario, take SUDS, block safety behaviours (closing eyes, looking down at the floor). (4) Post-exposure questioning. (5) Plan the transfer to real-life exposure. [synthesis based on in vivo procedure]
Example language (illustrative): "Keep your eyes on the window during the take-off. What do you predict will happen to you in the next two minutes?"
Watch for: Low presence (no fear = no test); VR becoming the only place the client can approach. [synthesis] [uncertain: no VR treatment manual cited]

4.30 Remote (telehealth) and therapist-guided field exposure

Purpose / when: When the client cannot attend, or the feared situation is at home or in the community. [source: job-file codebook notes (remote format)] [uncertain: no remote-exposure protocol cited; steps are synthesis]
Steps: (1) Confirm location and an emergency contact/plan at the start of each video session. (2) Check that a phone or video call does not become a safety signal; plan sessions where the client does the step without the call. (3) For field work, agree a meeting point, the client's right to stop, confidentiality in public, and how you will talk about the exposure in public places. (4) Use the client's camera to see the stimulus and the client's behaviour (e.g. walking into a shop, touching contaminated items). (5) Same expectancy, trial and post-exposure procedure as in the office. [synthesis]
Example language (illustrative): "Keep the phone in your pocket with the call open for this first trip; next time you'll do it with the phone switched off and ring me afterwards."
Watch for: Therapist voice becoming the safety behaviour; fade it.

4.31 Retrieval cues and relapse prevention

Purpose / when: Phase D. Helps the client retrieve the new learning when fear returns, and plans for lapses. [source: Craske et al., 2014; Wikipedia (relapse prevention typically included near the end)]
Steps: (1) Agree a retrieval cue (an object, a written reminder, mentally recalling a successful session), introduced late and used sparingly so it does not become a safety signal. (2) Explain return of fear: likely after stress, illness, a long gap or a new context, and not a sign that treatment failed. (3) Write a plan: early signs, the exposures to restart, how often. (4) Schedule self-directed exposures with increasing gaps. (5) Book a follow-up or booster if available. [source: Craske et al., 2014] [synthesis: steps 2–5 content]
Example language (illustrative): "If the fear comes back after a stressful month, that's your old learning resurfacing. You know the recipe: list what you've started avoiding and go straight back into it."
Watch for: Plans that rely on avoidance ("I'll just avoid lifts if it comes back").

4.32 Brief retrieval before extended exposure (reconsolidation-based timing)

Purpose / when: Experimental. A brief exposure to the feared cue about 30 minutes before an extended exposure session has reduced return of fear in some studies, but findings have not replicated consistently and timing is unclear. [source: Craske et al., 2014]
Steps: Optional: start a session with a very brief reminder presentation of the cue, a pause of about 30 minutes, then the main exposure. [source: Craske et al., 2014] [uncertain: not established; do not substitute for standard practice]
Example language (illustrative): "Take a quick look at the photo now, just a few seconds. We'll come back to it properly in half an hour."
Watch for: Nothing specific; use only as an add-on.

5. Handling problems

Items marked [source] come from the cited pages; everything marked [synthesis] is my own clinical guidance consistent with the rationale above.

Refuses to start / "I can't do that". Return to the formulation: what has avoidance cost, what would they do if the fear were gone (link targets to values-like goals). Offer a lower or modified step rather than dropping the target; model it first (4.8); for an unthinkable item, start with imaginal or VR as a bridge. Graded exposure lets clients stop at any time, so restating control often increases willingness. [source: Wikipedia (graded exposure); Div 12 (modelling, VR)] [synthesis: values link, sequencing]
Leaves the situation early. Do not treat it as failure; debrief what they predicted would happen if they had stayed. Re-enter at once at a slightly easier level if possible, so the last learning is approach. Agree a minimum duration before the next trial. [synthesis] Under habituation rules, escape at peak is a recognised risk for strengthening fear. [uncertain]
No fear at all during exposure. Check for hidden safety behaviours or signals (therapist, phone, medication, a "safe" person, distraction); check that the step targets the real feared outcome; move up or combine cues (4.13); try alone or in a new context. In interoceptive work, high similarity with low anxiety suggests safety cues in the room; set home practice. [source: Craske et al., 2014; Schmidt & Trakowski, 2004]
Fear does not come down within the session. Under the inhibitory approach this is expected and not a reason to stop or change course; ask whether the prediction was disconfirmed. Under habituation-based protocols (older PE, IOCDF), look for covert neutralising, mental distraction or reassurance, and extend duration. [source: Craske et al., 2014; IOCDF Scripting for Success]
Covert avoidance and safety behaviours. Ask directly after each trial what they did to keep safe; watch posture, gaze and breathing; ask a family member. Name substitutions (e.g. mental reviewing replacing checking). [source: Craske et al., 2014; IOCDF] [synthesis: observation methods]
Overwhelm, dissociation, panic in session. Stay calm and present; keep the client in the situation if it is safe and they can remain oriented, but step down to a smaller dose rather than ending in escape. In imaginal trauma exposure, reduce intensity: eyes open, past tense, more therapist talk, grounding to the room, then resume. Distinguish ordinary high fear (expected, not harmful) from loss of contact with the present (adjust). [synthesis] [uncertain: PE over-engagement adjustments are standard training content]
Physical problems during interoceptive or BII work. Any pain: stop that exercise. Fainting signs in BII: apply tension, sit or lie the client down, raise legs if needed; continue only when recovered. Unexpected chest pain, severe breathlessness or a seizure: stop and follow medical emergency procedure; do not resume without medical review. [source: ADAA (should not be painful); Leicestershire NHS leaflet (applied tension)] [synthesis: emergency steps]
Homework not done. Treat as information: review whether the task was too big, too vague or needed a safety behaviour removed too fast. Make tasks specific (day, time, place, duration), smaller, and planned in session; start the task in session; consider a support person for early tasks, then fade them. Homework review goes first each session. Adherence predicts outcome, so do not move on silently. [source: Wikipedia (homework adherence)] [synthesis: methods]
Exposures only done with the therapist or a companion. Plan fading of presence (4.8, 4.30) and schedule solo and unfamiliar-context trials. [source: Craske et al., 2014 (safety signals; alone and unfamiliar contexts)]
Reassurance seeking (OCD, health anxiety). Agree in advance that you will not answer reassurance questions; reflect the urge instead. Check that scripts and processing are not turning into reassurance. [source: IOCDF Scripting for Success (no reassurance in scripts)] [synthesis: in-session handling]
Rupture: anger at the therapist, "you're torturing me". Acknowledge the distress and the request as legitimate; return choice of pace to the client; re-explain the rationale using the client's own experience; repair before the next step. Ask for feedback at the end of exposure sessions. [synthesis]
Return of fear after gains. Normalise (expected after stress, gaps, new settings), use the relapse plan, restart exposure quickly, add variability and new contexts. [source: Craske et al., 2014; Wikipedia (relapse prevention)] [synthesis: normalising script]
Feared outcome actually happens (rejected, panics, vomits). Use it: debrief coping and consequences; this is the logic of occasional reinforced extinction for harmless outcomes. If the outcome was harmful, revisit the hierarchy for real-world risk. [source: Craske et al., 2014] [synthesis: debrief]
Unrealistic or untestable predictions (OCD, worry). Shift the target from disproving the catastrophe to tolerating uncertainty; use imaginal scripts ending in uncertainty. [source: IOCDF Scripting for Success]
Increase in symptoms early in trauma-focused exposure. Warn in advance that intrusions or distress may rise for a short time; monitor; continue unless risk changes. [synthesis] [uncertain: PE literature on symptom exacerbation]
Suicide or self-harm risk emerges. Pause exposure; conduct a standard structured risk assessment, collaborative safety plan and, where relevant, lethal-means counselling (safe storage or removal); resume exposure only when risk is managed under your service's protocol. [synthesis, consistent with standard practice]
Ongoing actual danger. If a "feared" situation turns out to be genuinely unsafe (e.g. continuing contact with a perpetrator), it is not an exposure target; switch to safety planning. [source: PE protocol outline (UW): exposures are to safe situations] [synthesis]
Substance use or benzodiazepines as safety signals. Agree not to use alcohol or as-needed medication to get through exposures, and coordinate with the prescriber on any medication changes (no dosing advice here). Craske et al.'s panic case removed carried benzodiazepines as a safety signal. [source: Craske et al., 2014] [synthesis: prescriber coordination]
Therapist avoidance or drift. Signs: always choosing easy items, ending early, adding relaxation, reassuring. Use supervision, plan items before the session, and remind yourself that exposure is designed to be uncomfortable. [synthesis]
Group delivery. Members' reactions can suppress fear (safety cues) or model avoidance; assign individual home practice and keep in-group exercises structured. [source: Schmidt & Trakowski, 2004] [synthesis]
Children. One-session treatment is used with children and adolescents; involve parents in practice planning and avoid parental reassurance as a safety signal. [source: Zlomke & Davis, 2008; ACAMH infographic] [synthesis: parent role]

Sources

Sources:

Further reading (not drawn on unless listed above): books and papers cited

Wolpe, J. (1958). Psychotherapy by Reciprocal Inhibition. Stanford University Press.
Marks, I. M. (1978). Living with Fear. McGraw-Hill.
Öst, L.-G., & Sterner, U. (1987). Applied tension: a specific behavioral method for treatment of blood phobia. Behaviour Research and Therapy.
Öst, L.-G. (1989). One-session treatment for specific phobias. Behaviour Research and Therapy.
Williams, S. L. (1990). Guided mastery treatment of agoraphobia. In Progress in Behavior Modification.
Craske, M. G., Antony, M. M., & Barlow, D. H. (1997). Mastery of Your Specific Phobia: Therapist Guide. Graywind/Oxford.
Craske, M. G., & Barlow, D. H. (2006). Mastery of Your Anxiety and Panic: Therapist Guide (4th ed.). Oxford University Press.
Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged Exposure Therapy for PTSD: Therapist Guide. Oxford University Press. (2nd ed. 2019 with Rauch.)
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H. (2011). Exposure Therapy for Anxiety: Principles and Practice. Guilford.
Craske, M. G., Treanor, M., Zbozinek, T. D., & Vervliet, B. (2022). Optimizing exposure therapy with an inhibitory retrieval approach and the OptEx Nexus. Behaviour Research and Therapy.

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