Cue-exposure therapy

1. Introduction

Version followed: abstinence-oriented cue-exposure treatment combined with urge-specific coping skills (CET-USCS) in the Monti/Rohsenow (Brown University) tradition, as operationalised in the Mellentin et al. (2017) aftercare protocol; Drummond-style "conventional" CET (exposure plus response prevention, no coping skills) and moderation-oriented CET (Heather, Sitharthan, Dawe, Kavanagh) are given as named variants. The Monti et al. (2002) manual itself is not drawn on [uncertain: session-level manual content is reconstructed from trial descriptions].

Cue-exposure therapy (CET) is a behavioural treatment for alcohol and other substance use disorders in which the client is repeatedly exposed, under controlled conditions, to the sights, smells, places, rituals and moods that have preceded their use, while use is prevented. The change model is Pavlovian: the substance (unconditioned stimulus) has been paired so often with cues that the cues alone now trigger conditioned responses, including craving; presenting the cues repeatedly without the substance weakens that link (extinction) [source: Mellentin et al. 2017; Martin et al. 2010; Drummond et al. 1990 as cited]. In the coping-skills variant a second mechanism is added: the client rehearses specific urge-coping strategies while the urge is live, so that coping, rather than drinking, becomes the practised response to cues and self-efficacy grows [source: Mellentin et al. 2017 app paper; Dolan et al. 2013 as cited]. Extinction is now understood to create new learning that competes with, rather than erases, the old association, so it is vulnerable to renewal (return of craving in a new context), spontaneous recovery (return with time) and reinstatement (return after re-exposure to the drug); good CET is built to protect against these [source: Conklin & Tiffany 2002 as cited in Mellentin et al. 2017 and Martin et al. 2010].

CET is a treatment component, usually added to standard addiction treatment or relapse-prevention CBT, not a stand-alone programme. Australian alcohol guidelines describe it as a specialist intervention for qualified practitioners [source: Guidelines for the Treatment of Alcohol Problems, 9.6].

2. Framework

Format across the trials [source: Mellentin et al. 2017, Table 1; Martin et al. 2010]: individual sessions in most protocols; inpatient (after detoxification) or outpatient; 6 to 16 sessions, typically 40 to 90 minutes; often several sessions per week. Examples: Monti et al. 1993, 6 sessions CET plus coping skills, inpatient; Drummond & Glautier 1994, 10 sessions, inpatient; Rohsenow et al. 2001, CET plus coping and communication skills; Loeber et al. 2006, nine 90-minute sessions over three weeks; Dawe et al. 2002, 8 outpatient sessions, moderation goal; Kavanagh et al. 2006, eight weekly 75-minute sessions for dysphoric drinkers; Heather et al. 2000, 16 sessions, moderation. Drug-use protocols (opiates, mixed) used 9 to 12 sessions, often 1 hour [source: Martin et al. 2010].

Phase 0. Assessment and preparation (1–2 sessions)

Goals: confirm suitability (Section 5 contraindications), complete detoxification, agree abstinence or moderation goal, map the client's personal cue profile, and give the rationale.
Havermans et al. used two sessions for rationale and personalised cue identification before nine exposure sessions [source: Martin et al. 2010].
Move on when: client is withdrawal-free and sober at session start, understands and consents to deliberate craving induction, has a written cue list ranked by expected urge, and a safety plan for after sessions [synthesis].

Phase 1. Urge-coping skills training (CET-USCS only; can overlap with Phase 2)

Goals: teach each urge-specific coping skill before it is used under exposure. In the Mellentin app protocol, four skills are trained in fixed order, and exposure without guidance unlocks only once all four are learned [source: Mellentin et al. 2017 app paper].
Move on when: client can describe and demonstrate each skill and has picked which skills fit which internal states [source: same; synthesis for the criterion wording].

Phase 2. In-session exposure with response prevention (bulk of treatment; roughly 6–10 sessions)

Goals: produce a genuine urge to the client's own cues, block drinking, rate urges, and either wait for the urge to fall (conventional CET) or apply coping skills while it is present (CET-USCS).
Progression: from less to more potent cues (look, then handle, then smell; then imagery, mood and context cues). Dawe et al. advanced to the next step only when urge ratings returned to within about 10% of baseline [source: Martin et al. 2010]. The Mellentin app allowed an exposure to stop once urge was 2 or lower on 0–10, but not before 8 minutes [source: Mellentin et al. 2017 app paper].
Move on when: the client's peak urge to a cue is lower, falls faster across sessions, and coping is used reliably without prompting [synthesis drawn from these criteria].

Phase 3. Generalisation (late sessions plus homework)

Goals: carry extinction and coping into everyday contexts, which is the main threat point (renewal). Options: homework exposure in real-world settings (Dawe et al.), varied rooms and cue sets, video or smartphone exposure practised in daily life, virtual-reality environments [source: Martin et al. 2010; Mellentin et al. 2017 app paper; Ghiţă et al. 2021].
In the Mellentin aftercare app, practice was once daily for up to 4 weeks; clients were told to use skills when they met risk situations but not to seek them out [source: Mellentin et al. 2017 app paper].

Phase 4. Consolidation and relapse prevention

Goals: plan for lapses (reinstatement risk), maintain coping, schedule boosters. VR booster sessions (six over five weeks) were used in one case report [source: Ghiţă et al. 2021]. Booster scheduling in general is [synthesis].

Package elements around CET. In Rohsenow et al. (2001), CET-USCS was delivered alongside communication skills training; in Monti's model CET sits within broader coping skills training (drink refusal, managing thoughts about alcohol, coping with cravings, negative moods) [source: Mellentin et al. 2017; Project MATCH CBT manual introduction; Monti et al. 2002, uncertain]. D-cycloserine has been tested as a pharmacological enhancer of extinction in research only; it is outside a psychotherapist's role and not covered here [source: Martin et al. 2010; Mellentin et al. 2017].

3. Guiding principles

[source: Mellentin et al. 2017 and app paper; Martin et al. 2010; Conklin & Tiffany 2002 as cited; individual practical meanings are synthesis unless marked]

Extinction requires non-reinforced exposure. The cue must be present and the substance must not follow; never let a session end in use.
Use the client's own cues. Preferred beverage, brand, glass, setting and mood carry the conditioning; generic cues produce weak urges [source: Mellentin app used beverage-specific videos; Martin et al. 2010 individualised cues].
Craving must actually be evoked. No urge, no extinction; check baseline and peak ratings each trial and increase cue potency if the peak is flat.
Stay with the urge until it comes down. Do not end an exposure at peak; use a minimum time and a falling-urge criterion.
Response prevention is explicit and agreed. The client knows in advance they will not drink (abstinence version) or will not exceed the priming dose (moderation version).
Coping is rehearsed under live urge (CET-USCS). Skills are practised while the cue is present, not just discussed [source: Dolan et al. 2013 as cited in Mellentin et al. 2017].
Match the skill to the client's state. Thinking about negative consequences suits positive mood or permissive thoughts; thinking about benefits of sobriety suits negative mood or urges to escape [source: Mellentin et al. 2017 app paper].
Go from less to more potent cues. Move up when urges at the current step have dropped near baseline.
Vary contexts and cues. Extinction is context-bound; practise in several rooms, times, moods and real-life settings to limit renewal [source: Conklin & Tiffany 2002 as cited].
Build bridges to real life. Use homework, portable reminders of treatment and real-world practice, without deliberately seeking high-risk situations [source: Martin et al. 2010; Mellentin app paper].
Plan for lapses. A drink after treatment can reinstate craving; prepare a lapse response in advance [source: Conklin & Tiffany 2002 as cited].
Safety first. The client is sober at session start, leaves only when urges are back to a manageable level, and has after-session support [synthesis; app protocol gave a therapist call line and locked use outside staffed hours].
Goal-specific design. Abstinence CET never includes tasting; moderation CET (priming dose) is only for clients for whom controlled drinking is a clinically appropriate goal [source: Mellentin et al. 2017 Table 1; Heather et al. 1993; suitability criteria are synthesis].

4. Intervention inventory

Sources for this section: Mellentin et al. 2017 (review and app paper), Martin et al. 2010, Heather et al. 1993, Ghiţă et al. 2021, USS-D study (2023). Where a step is not described in a cited source, it is tagged [synthesis]. All example language is illustrative unless quoted.

4.1 Suitability screen and consent

Purpose / when: Before any exposure. CET deliberately provokes craving; the client must be safe to experience it and agree to it.
Steps: (1) Confirm detoxification is complete and there are no active withdrawal signs; in inpatient trials CET began after detox [source: Mellentin et al. 2017; Martin et al. 2010]. (2) Screen for contraindications listed in Section 5. (3) Agree the treatment goal: abstinence (no tasting ever) or moderation (priming dose allowed). (4) Explain that urges will rise in session, that they pass, and that the client may pause but will not drink. (5) Agree the response-prevention rule, a stop signal and the after-session plan. (6) Record written consent [steps 2–6 synthesis].
Example language (illustrative): "In these sessions I'll deliberately bring up your urge to drink, with your own drink in the room. It will feel uncomfortable. The deal is that the drink stays untouched, and we stay with it until the urge settles."
Watch for: Ambivalence about the abstinence goal, hidden plans to drink after sessions, and agreement given only to please staff.

4.2 Rationale and psychoeducation on conditioned craving

Purpose / when: Session 1 (or first part of Phase 0). Gives the client a model that makes exposure make sense and that predicts the urge curve.
Steps: (1) Ask the client to name moments when craving appeared "out of nowhere" (a bar sign, a time of day). (2) Explain the pairing of cues with drinking and the learned urge, in plain language [source: Mellentin et al. 2017]. (3) Explain extinction: cue without drink, repeated, weakens the urge. (4) Describe the expected urge shape. The Mellentin app taught that urges tend to peak within about 4 minutes, decline after about 8 minutes and that urges fade faster with each exposure without drinking [source: Mellentin et al. 2017 app paper]. (5) Explain that new learning is context-bound, which is why practice will be varied and taken into daily life [source: Conklin & Tiffany 2002 as cited]. (6) Check understanding by asking the client to explain it back [synthesis].
Example language (illustrative): "Your brain has learned that the sight and smell of whisky mean whisky is coming. Each time you face those cues and nothing follows, it learns something new: this cue no longer means drinking."
Watch for: Fear that exposure will cause relapse; address it with the safety plan and the evidence from the client's own ratings over sessions.

4.3 Personal cue assessment and hierarchy

Purpose / when: Phase 0. Identifies the specific cues that will be used and their order.
Steps: (1) Interview the client about preferred beverages (type, brand, container, serving), drinking places, times, companions, rituals (pouring, opening), physical states and moods that precede drinking [source: individualised cue identification in Havermans et al. and Marissen et al., per Martin et al. 2010; categories listed are synthesis]. (2) For drug use, include paraphernalia, rituals and using locations [source: Bernaldo de Quirós Aragón et al., per Martin et al. 2010]. (3) Ask the client to rate the expected urge for each cue on 0–10. (4) Arrange cues into a graded sequence: for a proximal beverage cue, looking, then handling, then smelling [source: Dawe et al., per Martin et al. 2010]; then add imagery, mood and context. (5) Write the hierarchy down and review it each session.
Example language (illustrative): "Picture the last time you really wanted a drink. Where were you, what was in your hand, what did you smell, who was there, how were you feeling?"
Watch for: Lists limited to the drink itself; probe for emotional and situational cues, which often drive relapse.

4.4 Urge rating and monitoring

Purpose / when: Every exposure trial. Ratings show whether a real urge was evoked, guide when to move on and give the client evidence of change.
Steps: (1) Use a 0–10 urge scale (0 none, 10 severe). The Mellentin app shows it as a glass coloured green (0–2), yellow (3–6) and red (7–10) [source: Mellentin et al. 2017 app paper]. (2) Rate at baseline before the cue, at the expected peak (around 4 minutes) and at the end [source: same]. Dawe et al. rated urges every 4 minutes [source: Martin et al. 2010]. (3) Optionally record physical signs (salivation, restlessness) [synthesis; research protocols measured physiology]. (4) Chart peak and end ratings across sessions and show the chart to the client. The app derived urge intensity as peak minus baseline and skill effectiveness as peak minus end [source: Mellentin et al. 2017 app paper].
Example language (illustrative): "Before we bring the drink in, where's your urge right now, zero to ten? ... And now, with the glass in front of you?"
Watch for: Ratings that are always zero (avoidance, demand effects or under-reporting) or always maximal (overwhelm). Cross-check with observed behaviour.

4.5 In-vivo beverage cue exposure with response prevention (conventional CET)

Purpose / when: The core extinction procedure (Drummond-style conventional CET; also the exposure element of CET-USCS). Used across Phase 2.
Steps: (1) Breath-test or otherwise confirm sobriety at session start [synthesis; standard safety practice]. (2) Take baseline urge rating. (3) Present the client's preferred beverage in its usual container, served as they normally have it [source: Dawe et al. presented cues as normally served, per Martin et al. 2010]. (4) Work up the hierarchy: look at it, then hold it, then smell it (sniffing and handling the preferred beverage is described in Staciewicz et al., per Martin et al. 2010). (5) The client does not drink; if needed, the therapist keeps a hand near or the client places the drink down between steps. (6) Rate urges at intervals. (7) Continue until the urge has clearly fallen; criteria used include return to within about 10% of baseline (Dawe) or urge 2 or lower after at least 8 minutes (Mellentin app). (8) Repeat trials within the session if time allows; most included alcohol trials presented cues only once per session, which the review notes as a limitation [source: Mellentin et al. 2017]. (9) Remove and dispose of the drink in the client's sight at the end [synthesis].
Example language (illustrative): "Pick up the glass. Notice its weight and temperature... Now bring it towards your nose and breathe in the smell. What's happening in your mouth, your stomach? Rate the urge."
Watch for: Distraction or mental escape during exposure (staring away, chatting) that may blunt the urge; gently redirect attention to the cue. Signs it's working: lower peaks and faster declines across sessions, and the client reports fewer urges in daily life. Session lengths in trials ranged from about 40 to 90 minutes [source: Martin et al. 2010; Mellentin et al. 2017].

4.6 Imaginal exposure to high-risk drinking situations

Purpose / when: Adds context and situational cues that cannot be brought into the clinic. Combined with the real beverage or used alone; Havermans et al. combined cue and imagery exposure with response prevention [source: Martin et al. 2010]. Use in Phase 2 once beverage-only trials are producing manageable urges.
Steps: (1) Build a short script from the cue assessment, in the present tense, with sensory detail (place, sounds, company, the moment before ordering). (2) Client closes eyes or fixes gaze; therapist narrates for a few minutes, optionally with the beverage present. (3) Rate urge at baseline, peak and end. (4) Hold the scene until the urge falls, or, in CET-USCS, prompt a coping skill at peak (see 4.14). (5) Debrief on which details were most potent and use them next time [steps synthesis; imagery use sourced].
Example language (illustrative): "It's Friday, half past five. You've just walked out of work, the pub door is open, you can hear glasses and laughter. Your mate waves you in..."
Watch for: Scripts too vague to evoke urge, or traumatic material surfacing (pause and ground the client; see Section 5).

4.7 Emotional cue exposure (mood-induced craving)

Purpose / when: For clients whose drinking is driven by negative affect. Kavanagh et al. (dysphoric drinkers) added emotional cue exposure from session 3, after the client recalled negative experiences [source: Martin et al. 2010]. Bernaldo de Quirós Aragón et al. included emotional induction in their opiate hierarchy [source: same].
Steps: (1) Identify a moderately distressing, recent memory linked to urges (not a trauma memory) [synthesis]. (2) Ask the client to recall it in detail until mood shifts; rate mood and urge. (3) Introduce or keep the beverage present. (4) Continue exposure and rating until urge falls; in CET-USCS apply a mood-matched skill (4.11 for negative mood). (5) End with mood repair (brief positive activity or relaxation) before leaving [synthesis].
Example language (illustrative): "Go back to that row with your partner on Sunday. What were you telling yourself? Notice the pull towards the drink now."
Watch for: Mood not lifting at session end; depression or suicidal thoughts emerging (assess per Section 5).

4.8 Paraphernalia, ritual and context exposure (drug use disorders)

Purpose / when: For opiate, cocaine and other drug users whose cues are paraphernalia, preparation rituals and places. Bernaldo de Quirós Aragón et al. progressed from paraphernalia to emotional induction, drug rituals, then in vivo exposure to drug-using areas over 12 sessions [source: Martin et al. 2010].
Steps: (1) Use simulated or inert paraphernalia, photographs or video; never real drug [synthesis]. (2) Grade from handling items, to rehearsing the ritual with inert materials, to imagery, then accompanied visits to using locations [ordering per source; materials synthesis]. (3) Rate urge throughout and continue to decline as in 4.5.
Example language (illustrative): "Hold the spoon and the lighter as you would. Talk me through what you'd do next, but keep your hands still."
Watch for: Inpatient opiate CET (Marissen et al.) had more dropouts and higher relapse than a placebo-therapy control (relapse about 40% vs 13%) [source: Martin et al. 2010]. Use with extra caution and close follow-up in opioid users [synthesis].

4.9 Urge-specific coping skill: waiting it out (delay)

Purpose / when: First skill in the Mellentin CET-USCS sequence [source: Mellentin et al. 2017 app paper]. Useful for any urge; teaches that urges are time-limited.
Steps: (1) Teach the urge curve (4.2). (2) At peak during exposure, prompt the client to notice the urge, note the time and wait without acting. (3) Rate every minute or two until it falls. (4) Point out the drop. The app taught that the urge passes if one waits, and that it fades faster with repeated exposures [source: same]. (5) Turn it into a portable rule for daily life [synthesis].
Example language (illustrative): "It's at an eight. You don't have to do anything with it. Just watch the clock with me and let's see where it is in two minutes."
Watch for: White-knuckle suppression or rumination rather than observation; coach a neutral, curious stance [synthesis].

4.10 Urge-specific coping skill: thinking about negative consequences of drinking

Purpose / when: When the client feels good or has permissive thoughts ("one won't hurt") [source: Mellentin et al. 2017 app paper].
Steps: (1) Before exposure, help the client list specific, personal future harms of resuming drinking. The app used categories: physical health, mental health, family and friends, work and education, money, offences and loss of control; clients tagged 1–3 [source: same]. (2) Write them on a card. (3) At peak urge, the client vividly imagines those consequences, ideally a concrete scene. (4) Rate urge after 1–2 minutes. (5) Discuss which consequence images worked best [steps 3–5 synthesis on sourced skill].
Example language (illustrative): "Play the tape forward. You have this drink. Where are you at two in the morning? What does your daughter see in the morning?"
Watch for: Shame spirals; keep it future-focused and motivating rather than punitive.

4.11 Urge-specific coping skill: thinking about positive consequences of sobriety

Purpose / when: When the client is low, stressed or wants to drink to escape [source: Mellentin et al. 2017 app paper].
Steps: (1) List concrete benefits already gained and expected from not drinking (same life domains as 4.10). (2) At peak urge, the client imagines a specific scene of those benefits (waking clear-headed, a family event). (3) Rate urge; repeat with another benefit if needed [steps 2–3 synthesis].
Example language (illustrative): "Picture Saturday morning sober: what are you doing, who's with you, how does your body feel?"
Watch for: Benefits that are vague or not yet experienced; use small recent gains the client can actually recall.

4.12 Urge-specific coping skill: alternative food and beverage

Purpose / when: Gives the hand and mouth something to do in the moment and builds a new habit for risky situations [source: Mellentin et al. 2017 app paper]. Situations discussed in that session: being alone or at home after work, and social events [source: same].
Steps: (1) Agree on a non-alcoholic drink or snack the client likes (avoid alcohol-free beer or wine that mimics the cue, for abstinence-goal clients [synthesis; uncertain, no source cited addresses this]). (2) Have it in the room. (3) At peak urge, the client consumes it while the alcohol cue remains present. (4) Rate urge. (5) Plan where the alternative will be available in daily life.
Example language (illustrative): "Keep the beer where it is, open your sparkling water and take a long drink. What's the urge doing now?"
Watch for: Substitution with other substances; cigarette substitution was a negative predictor of outcome in one drug-treatment study [source: USS-D study 2023].

4.13 Additional urge-coping strategies

Purpose / when: Monti-tradition coping packages include more urge strategies than the four in the Mellentin app. An urge-coping questionnaire adapted from the alcohol version lists, among others: alternative behaviour, distracting thoughts, relaxation and meditation, challenging negative thoughts, thinking through the behaviour chain, problem-solving, stress mastery, drink or drug refusal skills [source: USS-D study 2023]. Which of these were rehearsed under exposure in Monti/Rohsenow CET is [uncertain: manual].
Steps (each, rehearsed at peak urge) [synthesis]: Alternative behaviour: client does a brief incompatible action (stands, leaves the table, texts a support person) and rates urge. Relaxation: slow breathing for 1–2 minutes with the cue present. Challenging thoughts: client names the permission-giving thought aloud and answers it. Behaviour chain: client traces the steps from cue to drink and names where they will step off. Refusal: role-play turning down an offered drink while holding the cue.
Example language (illustrative): "What's the thought that's selling you this drink? Say it out loud... Now, what would you say back?"
Watch for: Relaxation or distraction used as a way to avoid the cue entirely; it should be used with the cue in view.

4.14 Integrated CET-USCS exposure trial

Purpose / when: The standard Phase 2 trial in the version followed: exposure first, coping at peak, exposure continued until urge is manageable.
Steps: (1) Baseline urge rating. (2) Present cue (beverage, plus imagery or mood as the hierarchy dictates). (3) Let the urge build; at about 4 minutes, rate it and prompt the client to use a chosen skill [source: Mellentin et al. 2017 app paper]. (4) Continue cue presence while the skill is applied. (5) End rating; stop only when urge is 2 or lower and at least 8 minutes have passed (app rule) [source: same]. (6) Debrief: which skill, how much did the urge drop (peak minus end). (7) Rotate skills across trials and match them to mood [source: same].
Example language (illustrative): "It's at seven now. Which skill fits how you feel right now? Go ahead and use it, keep the glass in your hand."
Watch for: Skills used so early that the urge never builds; let the urge rise before prompting.

4.15 Moderation-oriented CET with a priming dose (variant)

Purpose / when: For clients with a clinically appropriate controlled-drinking goal (trials recruited sub-clinical or problem drinkers, not severely dependent inpatients) [source: Mellentin et al. 2017 Table 1]. The target is the urge to continue after the first drink. Never with an abstinence goal.
Steps: (1) In clinic, the client takes a priming dose of their preferred drink [source: Heather et al. 1993; Dawe et al. and Kavanagh et al. per Martin et al. 2010]. The dose size is not given here (protocol-specific, set by the treating team) [uncertain]. (2) Further drinks are then presented, and the client looks, handles and smells them while resisting further drinking [source: Dawe et al., per Martin et al. 2010]. (3) Rate urges about every 4 minutes; move up the hierarchy only when urges return to within about 10% of baseline [source: same]. (4) Progress from formal clinic exposure, to supervised practice, to unsupervised practice of resisting continued drinking in tempting real situations [source: Heather et al. 1993]. (5) Assign real-world homework exposures [source: Dawe et al., per Martin et al. 2010]. (6) Confirm the client is safe to travel home (no driving after a priming dose) [synthesis].
Example language (illustrative): "You've had your one glass, which is your planned limit. The second one is right here. Notice the pull to keep going, and let's watch what it does."
Watch for: Loss of control in session, escalating between-session drinking, or the client using sessions as permission. Switch to an abstinence goal if moderation repeatedly fails [synthesis].

4.16 Real-world (in vivo) homework exposure

Purpose / when: Phase 3. Extends extinction beyond the clinic, where renewal is most likely.
Steps: (1) Choose a graded real-life cue situation from the hierarchy (walking past the off-licence, sitting in a café where others drink). (2) Plan duration, coping skills, an exit plan and a support contact. (3) Client rates urge at start, peak and end, and logs it. (4) Review at the next session [source: Dawe et al. homework, per Martin et al. 2010; structure synthesis]. In the abstinence aftercare app, clients were told not to seek out risk situations but to use skills when they met them [source: Mellentin et al. 2017 app paper]: choose the more conservative stance for severely dependent clients [synthesis].
Example language (illustrative): "This week, walk the drinks aisle once, slowly, and rate the urge at the start, the peak and when you leave. Text me the numbers."
Watch for: Unplanned prolonged exposure, going in already distressed or drinking; review lapses non-judgementally (Section 5).

4.17 Multiple contexts and retrieval cues

Purpose / when: Throughout Phase 2–3, to limit renewal. Recommended by Conklin & Tiffany and discussed in the reviews [source: Mellentin et al. 2017; Martin et al. 2010]. Evidence is mixed: some studies found renewal and others did not [source: Martin et al. 2010].
Steps: (1) Vary the room, time of day, beverage type and the client's mood across sessions. (2) Use real-world contexts as treatment advances. (3) Give the client a small portable reminder of treatment (an extinction reminder; Collins & Brandon used a coloured clipboard and pencil in the lab) to carry into risky contexts [source: Martin et al. 2010]. (4) Space sessions out as treatment progresses [source: Martin et al. 2010 recommendations; schedule is synthesis].
Example language (illustrative): "Today we'll do this in the kitchen area rather than the office, and with the red wine rather than beer."
Watch for: Urges that are low in the usual room but jump in a new one: this is renewal, so add that context to practice.

4.18 Video and smartphone CET

Purpose / when: Aftercare or between-session practice when in vivo materials are impractical.
Steps (Mellentin app protocol): (1) Train the four coping skills first, in order. (2) The client chooses a beverage video (eight types, using common local brands), lasting 15 minutes, in which alcohol becomes more appetising. (3) Rate urge at baseline, about 4 minutes and the end; at 4 minutes the app prompts a coping skill. (4) Exposure may stop when urge is 2 or lower after at least 8 minutes. (5) Practice once daily for up to 4 weeks, with text reminders. (6) A call button reaches a therapist in staffed hours; the app is locked outside them [source: Mellentin et al. 2017 app paper].
Example language (illustrative): "Choose the drink you'd normally have tonight, and do the session somewhere different from yesterday."
Watch for: Daily urge graphs that are rising, or use at night when alone; review data at each contact.

4.19 Virtual-reality cue exposure

Purpose / when: Delivers contexts (bars, parties, home) and preferred drinks that cannot be staged in clinic. Studies used 1–8 sessions of 13–30 minutes [source: Martin et al. 2010]; one severe-AUD case had six VR booster sessions over five weeks with preferred beverages and alcohol-related contexts [source: Ghiţă et al. 2021].
Steps: (1) Select environments matching the client's hierarchy. (2) Rate urge and anxiety during each VR exposure [source: Ghiţă et al. 2021]. (3) Apply the same continue-until-decline rule and coping prompts as in clinic [synthesis]. (4) Screen for cybersickness and photosensitive epilepsy [synthesis].
Example language (illustrative): "You're at the bar now. Look along the shelf. Find your bottle. What's the urge?"
Watch for: Low presence (no urge); add real smell cues if allowed in your setting [synthesis].

4.20 Extinction-enhancing adjustments from inhibitory learning [synthesis]

Purpose / when: Optional refinements borrowed from anxiety exposure research; not tested as such in the CET sources [uncertain].
Steps: (1) Before each trial, ask the client what they expect ("the urge will become unbearable", "I'll have to drink") and afterwards what actually happened. (2) Combine cues once each is extinguished separately (beverage plus mood plus imagery). (3) Vary cue order and intensity rather than always climbing smoothly. (4) Fade safety behaviours, such as the therapist's hand near the glass, as competence grows.
Example language (illustrative): "You predicted you couldn't sit with it past five minutes. It's been twelve. What does that tell you?"
Watch for: Overreaching; increase difficulty only when the client is reliably coping.

4.21 Session closure and after-session safety check

Purpose / when: End of every exposure session.
Steps: (1) Remove all cues from the room. (2) Final urge rating; do not let the client leave while urge is high: continue coping or a neutral activity until it is low [synthesis; consistent with the app's end-of-exposure criterion]. (3) Review the plan for the next few hours (where they are going, who they'll be with, what they'll do if urges return). (4) Confirm the support contact; the app provided therapist contact during staffed hours and support numbers [source: Mellentin et al. 2017 app paper]. (5) Brief summary of what was learned.
Example language (illustrative): "Before you go: where's the urge now, and what's the plan for this evening if it comes back?"
Watch for: Delayed craving later the same day; ask about it at the next session and adjust the plan.

5. Handling problems

The sources say little about clinical problem-handling; most guidance below is [synthesis] unless a source is named.

Contraindications and cautions before starting [synthesis unless marked]

Not intoxicated or in withdrawal; inpatient CET began after detox [source: Mellentin et al. 2017].
Defer for acute suicidality, active psychosis, unstable medical illness, or severe cognitive impairment (the app was simplified for mild to moderate cognitive impairment [source: Mellentin et al. 2017 app paper]).
No priming dose (moderation CET) for severe dependence, pregnancy, liver disease, an abstinence goal, or anyone taking alcohol-interacting medication such as disulfiram; check with the prescriber.
Opioid users: CET in one inpatient trial had higher relapse and dropout than control [source: Martin et al. 2010]; use only with close monitoring and overdose-prevention planning.

Client produces no urge (stuck at 0–2). Check sobriety and medication that dampens craving; increase cue potency (preferred brand, real serving ritual, smell, add imagery or mood induction, a more realistic context); look for covert avoidance (looking away, mental distraction). If urges never rise, extinction cannot be shown; consider whether CET fits this client.

Overwhelm (urge 9–10, distress, agitation). Step down the hierarchy (look only, greater distance), shorten trials, prompt a coping skill earlier, and lengthen the session so the urge can fall before leaving. Never end on a peak. If distress is trauma-related, stop exposure, ground the client and reformulate.

Urges do not decline across sessions. Check between-session drinking (reinforcement undermines extinction; reinstatement after drug re-exposure is a named threat [source: Conklin & Tiffany 2002 as cited]); check whether the client is truly engaging with the cue; increase trials per session (most alcohol trials used only one presentation per session [source: Mellentin et al. 2017]); add coping skills if running conventional CET (larger effects were seen with CET plus urge-specific coping [source: Mellentin et al. 2017]).

Gains in clinic, craving in daily life (renewal). Expected: extinction is context-specific [source: Conklin & Tiffany 2002 as cited]. Map the contexts where urges returned and add them to practice (imagery, VR, accompanied or homework exposure), give a portable treatment reminder, and space sessions [source: Martin et al. 2010 recommendations].

Lapse or relapse during treatment. Treat a lapse as information: identify the cue chain, check whether the cue was on the hierarchy, and plan exposure to it. Reassess goal (moderation to abstinence) and level of care. Do not run exposure on a day the client has been drinking; reschedule after sobriety is confirmed.

Craving after the session / fear the treatment causes relapse. Use the closure routine (4.21); arrange contact for that evening; schedule sessions earlier in the day; review urge charts showing declining peaks. The app restricted use to staffed hours for this reason [source: Mellentin et al. 2017 app paper].

Resistance and dropout. Dropout was often higher in CET than control arms (for example 44% vs 34% in one trial) [source: Martin et al. 2010]. Spend more time on rationale and choice; let the client set the pace of the hierarchy; use motivational interviewing to link exposure to the client's own goals; start with less potent cues to build early success.

Non-adherence to homework or app practice. Make tasks smaller and specific (time, place, duration), use reminders (the app used texts [source: Mellentin et al. 2017 app paper]), review the urge log first thing each session, and problem-solve barriers.

Rupture (client feels tested, tricked or shamed by having alcohol in the room). Name it, validate the discomfort, revisit consent and the shared rationale, hand control of pacing back to the client, and repair before resuming.

Client tries to drink in session. Calmly remove the drink, stop the trial, explore what happened, and revisit consent. If it recurs, reconsider suitability and setting (inpatient rather than outpatient).

Substitution with other substances or behaviours. Monitor nicotine, cannabis and food use; cigarette substitution was a negative predictor of outcome in one study [source: USS-D study 2023]. Steer alternative-food/beverage practice toward neutral choices.

Comorbid anxiety or depression. Emotional cue exposure (4.7) was used with dysphoric drinkers [source: Martin et al. 2010]; monitor mood each session and treat the comorbid problem in parallel.

Sources

Sources:

Further reading (not drawn on): Monti & Rohsenow (1999), Coping-skills training and cue-exposure therapy in the treatment of alcoholism, Alcohol Research & Health 23(2) [uncertain: its procedural content is not reflected directly here].

Further reading (not drawn on; cited via the sources above):

Monti, P. M., Kadden, R. M., Rohsenow, D. J., Cooney, N. L., & Abrams, D. B. (2002). Treating Alcohol Dependence: A Coping Skills Training Guide (2nd ed.). Guilford.
Drummond, D. C., Tiffany, S. T., Glautier, S., & Remington, B. (Eds.) (1995). Addictive Behaviour: Cue Exposure Theory and Practice. Wiley.
Drummond, D. C., Cooper, T., & Glautier, S. P. (1990). Conditioned learning in alcohol dependence: implications for cue exposure treatment. British Journal of Addiction.
Drummond, D. C., & Glautier, S. (1994). A controlled trial of cue exposure treatment in alcohol dependence. Journal of Consulting and Clinical Psychology.
Conklin, C. A., & Tiffany, S. T. (2002). Applying extinction research and theory to cue-exposure addiction treatments. Addiction.
Marlatt, G. A. (1990). Cue exposure and relapse prevention in the treatment of addictive behaviors. Addictive Behaviors.
Rohsenow, D. J., et al. (2001). Cue exposure with coping skills training and communication skills training for alcohol dependence: 6- and 12-month outcomes. Addiction.
Dolan, S. L., et al. (2013). Urge-specific coping strategies and treatment outcome (as cited in Mellentin et al. 2017).

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