Applied tension

1. Introduction

Version followed: Öst & Sterner (1987) five-session applied tension (AT) for blood(-injection-injury) phobia, plus the compressed one-session format tested by Hellström, Fellenius & Öst (1996). The 1987 paper itself is not drawn on [uncertain]. Its structure is reconstructed from the Division 12 entry and from studies that report following it. Practice timings are cross-checked against the Craske, Antony & Barlow (2006) workbook, as reported in Chapman & DeLapp (2013). Where versions give different numbers, both are shown.

Applied tension is a brief, skills-plus-exposure treatment for people with blood, injury or injection (BII) fears who faint or nearly faint. Most phobias show only rising arousal. BII phobia often shows a biphasic response: heart rate and blood pressure first rise, then drop sharply (vasovagal reaction). Less blood reaches the brain, causing light-headedness, nausea, blurred vision and sometimes fainting. AT teaches the client to tense large skeletal muscles and so raise blood pressure. The client learns to spot the first signs of the drop, then applies tension during graded exposure to blood and injury stimuli. Theory of change: tension stops the faint, so the client can stay in the situation. Repeated exposure without fainting then weakens the fear and the vasovagal reaction. Each success also shows the client that they can control the drop. [source: Div 12 Exposure Therapies for Specific Phobias; Nieto Centeno & Mas Hesse 2002 abstract; Wannemueller et al. 2018; Chapman & DeLapp 2013]

AT was developed by Lars-Göran Öst and Ulf Sterner in Sweden. It builds on earlier muscle-tension case work by Kozak & Montgomery (1981). [source: Div 12; Wannemueller et al. 2018; Between Sessions handout credits Kozak & Montgomery]

2. Framework

Format: individual, outpatient. Original version: 5 sessions of about an hour [uncertain: exact length not confirmed], plus a self-exposure maintenance programme. Compressed version: one longer session, which Hellström et al. (1996) found to work about as well as five [source: Wannemueller et al. 2018 summary of Hellström et al. 1996; Chapman & DeLapp 2013 cite it]. AT has also been delivered as a one-session large-group format, with about 20 minutes of tension training inside a session of about 160 minutes. A therapist demonstrated the technique, and medical staff were present throughout [source: Wannemueller et al. 2018]. In wider CBT packages, AT is one module, introduced after hierarchy building and before graded exposure (e.g., session 5 of a 9-session manualised CBT case) [source: Chapman & DeLapp 2013].

Phases. Session allocation follows secondary descriptions of the five-session format [uncertain where marked].

Phase	Goal	Typical timing	Move on when
0. Assessment and medical check	Confirm BII fear with a fainting or near-fainting history; map triggers, avoidance and the order of symptoms; rule out medical causes of fainting	Before or at session 1	Medical causes considered; client agrees to the rationale
1. Rationale and tension training	Explain the biphasic response; teach tension; show its effect (feeling of warmth in the face; blood-pressure reading if available)	Session 1	Client can produce the tension–release cycle correctly; home practice set
2. Home practice	Overlearn the skill so it is automatic under stress	About 1 week (5 times a day in the workbook version) [source: Chapman & DeLapp 2013; Between Sessions 2018]	Practice logged; no troublesome side effects
3. Early-warning-sign training	Identify the client's very first cues of the blood-pressure drop	Session 2 onward [uncertain: exact session]	Client can name their own first cues and starts tensing when they appear
4. Applied practice with exposure	Use tension during graded exposure: pictures or slides of wounds, then live blood stimuli such as a finger prick, watching or giving a blood donation, and watching surgery or other medical procedures	Sessions 2–5 [uncertain: which stimulus in which session]	Client stays through each item without fainting; fear ratings drop; tension starts without a prompt
5. Maintenance programme	Continued self-exposure in daily life; keep the skill ready for real medical events	After the last session	Client has a written plan and is booking the medical procedures they had avoided

The one-session format packs phases 1, 3 and 4 into a single long session. Home practice and maintenance then carry the rest [source: Wannemueller et al. 2018 on Hellström et al. 1996; detail of the one-session sequence [uncertain]].

Variants named in the Öst research programme: applied tension (tension plus exposure); tension-only (the tension skill without its planned use during exposure); exposure in vivo alone; and applied relaxation, which was compared against AT. All were tested in five-session formats [source: Div 12 reference list: Öst, Sterner & Fellenius 1989; Öst, Fellenius & Sterner 1991; Wannemueller et al. 2018 on Ayala et al. 2009].

3. Guiding principles

Target the faint, not just the fear. In practice: assess whether the client faints or nearly faints, and use AT mainly when they do. A client with pure needle fear and no fainting may need standard exposure only [source: CCI sheet frames AT for clients with a fainting history or fear of fainting; Div 12].
Tension, then back to normal, never deep relaxation. In practice: after each release, the client returns to a normal state, not a deeply relaxed one, because relaxation can lower blood pressure further [source: Between Sessions 2018; Chapman & DeLapp 2013].
Skill before stimulus. In practice: do not use a high-fainting-risk item until the client can use tension reliably. In the workbook version that means about a week of successful practice [source: Chapman & DeLapp 2013].
Apply early. In practice: tense at the first sign of the drop, not once the client is already faint. Signal training is the active ingredient that turns 'tension' into 'applied tension' [source: Nieto Centeno & Mas Hesse 2002; Navarrete López & Rando Hurtado case; Wannemueller et al. 2018].
Exposure does the long-term work. In practice: tension buys time in the situation, and staying for repeated, prolonged exposure is what reduces fear [source: Chapman & DeLapp 2013; Div 12].
Graded and repeated. In practice: build a 0–10 or 0–100 hierarchy, and repeat each step until distress drops before moving up [source: CCI sheet; Chapman & DeLapp 2013; Navarrete López & Rando Hurtado].
Safety is planned, not improvised. In practice: the client is always seated or reclined during exposure, a fall-safe set-up is in place, and medical staff are present for live blood or needle procedures [source: Wannemueller et al. 2018 recommends medical staff on site; seating per Between Sessions and CCI; reclining set-up [synthesis]].
Real-world transfer. In practice: the goal is to get through the actual procedures the client has avoided, such as blood tests, injections, vaccinations and dental or hospital care. Plan these as the final steps [source: Nieto Centeno & Mas Hesse 2002; Chapman & DeLapp 2013].
Measure. In practice: record distress before, during and after each exposure, plus any faintness signs. If a cuff is available, measure blood pressure to show that tension works [source: Chapman & DeLapp 2013].

4. Intervention inventory

The AT package has six core elements: assessment, rationale, the tension skill, home practice, early-warning-sign training, and applied practice in graded exposure; maintenance follows. The other items are formats, adaptations or add-ons from the studies and handouts cited. Each is labelled with its origin. All example wording is illustrative, not quoted from Öst.

4.1 Assessment of the fainting pattern and medical screening

Purpose / when: Before treatment. Establish whether the client has the biphasic, fainting-prone pattern AT targets, and rule out other causes of fainting.
Steps:
1. Take a fear and fainting history: first episode, how many faints or near-faints, the triggers (sight of blood, injections, wounds, medical talk, hospital smells), and what the client avoids (blood tests, vaccinations, dental care, pregnancy care, visiting sick relatives) [source: Chapman & DeLapp 2013 fear-acquisition and avoidance forms].
2. Map the order of symptoms in a typical episode. Early: heart pounding, sweating, fear. Later: light-headedness, warmth or cold, nausea, tunnel or blurred vision, ringing ears, weakness, then fainting. The later, vasovagal signs are the cues AT will target [source: Wannemueller et al. 2018 sympathetic vs vasovagal classification; Nieto Centeno & Mas Hesse 2002].
3. Ask about disgust as well as fear. Strong disgust at blood or bodily reminders predicts fainting and can fade more slowly with exposure [source: Chapman & DeLapp 2013 citing Olatunji et al. 2006, 2007].
4. Medical screening: [synthesis] Ask the client to discuss AT with their physician before starting if they have fainting outside blood or needle situations, fainting during exertion, known heart disease or arrhythmia, uncontrolled high blood pressure, a history of stroke or aneurysm, pregnancy with a blood-pressure complication, or anything else that makes deliberate blood-pressure rises or strong muscle effort inadvisable. Also check medicines that affect heart rate or blood pressure (e.g., beta-blockers). The original reports do not list contraindications [uncertain].
5. Set baseline measures: a hierarchy with distress ratings (see 4.6), and optionally a standardised BII fear questionnaire. Describe licensed scales by name only.
Example language (illustrative): "Talk me through the last time you had blood taken, second by second. What did you notice first in your body, and what came next?"
Watch for: fainting with no blood or needle trigger, which points to a medical cause and needs referral first; panic attacks outside medical settings (comorbid panic needs its own plan); needle fear without any faintness, where plain exposure may be enough.

4.2 Rationale: the biphasic response

Purpose / when: Session 1. Makes the technique make sense and reduces the shame many clients feel about fainting.
Steps:
1. Draw two lines over time on paper: blood pressure and heart rate go up, then fall sharply. Mark where faintness appears.
2. Explain that the drop is a reflex, not weakness or 'losing it'. It reduces blood flow to the brain, causing the faint [source: Nieto Centeno & Mas Hesse 2002; Wannemueller et al. 2018].
3. Explain the tension logic: tensing big muscles pushes blood pressure back up and blocks the drop [source: Nieto Centeno & Mas Hesse 2002; Div 12].
4. Explain the plan: learn the skill, learn the first warning signs, then practise with gradually harder blood and injury material until real procedures are manageable.
5. Keep the teaching materials mild. In one study, eight participants fainted or nearly fainted during an educational video, and the authors advise making psychoeducation less graphic [source: Wannemueller et al. 2018].
Example language (illustrative): "Your body is doing something quite unusual here. Most fears just ramp you up. With blood, your system ramps up and then over-corrects and drops your blood pressure. The drop is what makes you faint, and we can block it with your own muscles."
Watch for: relief or 'aha' responses (good); a client who hears 'reflex' as 'nothing can be done' (stress that the reflex can be counteracted); faintness during the explanation itself, which means the rationale is already exposure: seat the client and tense together.

4.3 Tension technique training

Purpose / when: Session 1, after the rationale. Builds the core skill.
Steps [source: Chapman & DeLapp 2013 (workbook protocol); Between Sessions 2018; CCI sheet; Wannemueller et al. 2018. Timings differ by version, see below]:
1. Client sits in a comfortable chair.
2. Demonstrate first, then have the client tense the large muscles of the arms, torso and legs together (thighs, buttocks, stomach, arms, fists).
3. Hold the tension until a feeling of warmth or a 'rush' rises in the face or head. Versions give about 10–15 s (workbook), about 15 s (CCI) or 15–20 s (Wannemueller et al. leg-and-buttock first, then arms added).
4. Release and let the body return to normal, not deep relaxation, for about 20–30 s (CCI: at least 30 s).
5. Repeat for 5 cycles.
6. Coach the client to keep breathing normally while tensing and not to hold their breath. [synthesis: avoids breath-holding effects that can themselves cause light-headedness; not specified in the sources]
7. If a blood-pressure cuff is available, measure before and after a set so the client sees the rise [source: Chapman & DeLapp 2013; BP demonstration in the original Öst sessions [uncertain]].
Example language (illustrative): "Now tense your arms, chest, stomach and legs all at once. Hard, but not so hard that it hurts. Keep breathing. Hold… notice the warmth coming up into your face? Good. Now let go, and just sit normally. Don't go floppy, just ordinary."
Watch for: face flushing or warmth, which shows it is working; headache (see section 5); muscle pain or cramp, so reduce force; client relaxing deeply after release, so correct it; tensing only the hands or face. During later needle work, the arm receiving the needle stays relaxed (see 4.9).

4.4 Home practice

Purpose / when: Between session 1 and the first high-fainting-risk exposure. Overlearning makes the skill automatic.
Steps:
1. Set a schedule: 5 cycles per practice session, 5 practice sessions a day, for about a week (workbook version). The CCI version is twice daily [source: Chapman & DeLapp 2013; Between Sessions 2018; CCI sheet].
2. Practise seated at home. Log the date, time, cycles done and any side effects.
3. Clients worried about fainting during practice can have someone nearby [source: Between Sessions 2018].
4. Review the log next session; correct technique by having the client demonstrate.
Example language (illustrative): "Think of this like learning to brake. Practise it so often this week that when you're in the clinic, your body does it without you having to think."
Watch for: missed practice (see section 5); practice done lying down only; headaches building up across the day.

4.5 Early-warning-sign identification

Purpose / when: From session 2, before and during exposure. The client learns to recognise the very first sign of the blood-pressure drop so tension starts in time. This step turns the tension skill into applied tension.
Steps:
1. Using the symptom sequence from 4.1, help the client pick out their earliest personal cue. Common ones are a faint 'odd' feeling in the head, a change in vision, a cold sweat, slight nausea or a sinking feeling [source: Nieto Centeno & Mas Hesse 2002; Wannemueller et al. 2018; the list of examples is [synthesis]].
2. Teach the client to tell these drop signs apart from ordinary fear arousal such as a pounding heart [source: Wannemueller et al. 2018 sympathetic vs vasovagal classification].
3. Present mild stimuli and ask the client to signal the moment they notice a cue (e.g., raising a finger), then tense straight away.
4. Review afterwards: was tension early enough? Move the trigger point earlier if faintness built up first.
Example language (illustrative): "As soon as you notice that first hint of the 'drain' feeling, even before you're sure, start tensing. Earlier is always better than later."
Watch for: clients waiting until they are certain (too late); confusing arousal with the drop, which is harmless if they tense anyway, but explain the difference; clients who have no cues before fainting (see section 5).

4.6 Building the exposure hierarchy

Purpose / when: Sessions 1–2, or before AT in a wider CBT package. Orders the exposure work.
Steps:
1. List blood, injury and injection situations; rate each on a 0–100 distress scale (some cases use 0–10).
2. Cover the client's own triggers. Typical categories: pictures of medical equipment and needles; photos of wounds or scars; video of injections or blood draws; handling real equipment (tourniquet, capped needle); finger-prick testing; watching someone else's blood draw or injection; one's own blood test, injection or vaccination; watching surgery or other procedures.
3. Limit to about 10–15 steps and include any medical procedure the client actually needs to have. [source: CCI sheet example hierarchy; Chapman & DeLapp 2013 10-item hierarchy; Navarrete López & Rando Hurtado 30-image hierarchy; Öst-programme items (wound slides, blood donation, surgery observation) per secondary reports [uncertain]]
Example language (illustrative): "Let's list everything that sets this off, from 'mildly uncomfortable' up to 'the worst I can imagine', then score each one out of 100."
Watch for: gaps that are too large between steps; avoidance of the top item. Real-life medical needs should be on the list even if they come last.

4.7 Applied tension during picture and video exposure

Purpose / when: From session 2. This is the first time the client applies the skill to a blood stimulus, in a controlled setting.
Exposure consent and safety: [source for seating and medical presence: Wannemueller et al. 2018; Between Sessions 2018; consent and set-up steps [synthesis]]
- Get informed consent for exposure. Explain that faintness may happen, that the client can pause at any time, and that the client is choosing to stay as long as they can.
- Seat the client in a stable chair with arms, ideally one that reclines, with nothing hard nearby and space to lie down. Never do it standing.
- Agree a stop signal.
Steps:
1. Show pictures one at a time, starting low on the hierarchy. The Öst studies used slides of wounded people [uncertain on number]. One case study used a 30-image hierarchy, and Wannemueller et al. showed each picture for 60 s.
2. The client watches, monitors for early cues and tenses on any cue (4.5). Between tension cycles they return to normal, not relaxed.
3. Ask for distress and faintness ratings every 30–60 s.
4. Repeat each picture or clip until distress falls clearly; in one case study this meant repeating until the rating reached 0. Then move on.
5. Progress to video, e.g., a blood draw. Wannemueller et al. used a video of the therapist having blood drawn while describing his own sensations. [source: Wannemueller et al. 2018; Navarrete López & Rando Hurtado]
Example language (illustrative): "Keep looking at the picture. Notice what your body does. Any hint of the drain? Tense now: arms, body, legs. Good, and back to normal. Keep your eyes on it."
Watch for: looking away, blurred focus or distraction, which are subtle avoidance; facial pallor, sweating or slumping, so prompt tension at once; distress falling within and across exposures, which shows it is working.

4.8 Applied tension during in vivo exposure

Purpose / when: Mid to late treatment (sessions 3–5 in the five-session format). Transfers the skill to live blood and medical situations.
Steps:
1. Arrange settings with medical cooperation. Options include handling equipment; a finger prick, done by a nurse or by the client; watching a blood donation or blood draw (the Öst studies used blood donation [uncertain]; Wannemueller et al. used a live draw on a volunteer); visiting a hospital ward; and, in the original programme, watching surgery (thoracic surgery is reported in secondary descriptions [uncertain]). Medical staff should be present for any live blood procedure [source: Wannemueller et al. 2018].
2. Before entering, rehearse a few tension cycles. The client stays seated during live procedures.
3. Approach in steps: watch from a distance, then close up (in Chapman & DeLapp's case, about 1 m from a blood bank procedure), then have the procedure done to oneself.
4. The client watches the procedure, tenses on cues and stays until distress settles. Repeat if possible.
5. Debrief: what cues appeared, when the client tensed and what happened. [source: Chapman & DeLapp 2013 sessions 6–9; Nieto Centeno & Mas Hesse 2002; Wannemueller et al. 2018; CCI sheet]
Example language (illustrative): "The nurse is going to start now. Keep watching her hands. Tense when you need to, and keep your left arm loose for her."
Watch for: fainting despite tension (see section 5); clients who 'get through' by not looking, so check where their attention is; success shows when the client completes their own procedure without fainting, then does it again.

4.9 Needle-arm modification

Purpose / when: Any injection or blood-draw step, in session or in real life.
Steps: Keep the arm receiving the needle relaxed and tense the other arm, the torso and the legs. Tensing the needle arm is said to increase pain [source: Between Sessions 2018]. [synthesis] Tell the clinician doing the procedure what the client is doing, and time the cycles so the needle arm is still at the moment of insertion.
Example language (illustrative): "Let this arm go heavy on the table. Everything else, tense."
Watch for: the client stiffening the target arm without meaning to; the procedure being harder for the clinician.

4.10 Managing a faint or near-faint in session

Purpose / when: Whenever faintness keeps rising despite tension, or the client faints.
Steps: [synthesis: standard first-aid practice, not described in the AT sources]
1. Stop the stimulus. Help the client lie down with legs raised, or sit leaning forward if lying down is not possible. Loosen tight clothing.
2. Once lying down, the client can keep tensing their legs and body.
3. Recovery from a vasovagal faint is usually quick. If consciousness does not return promptly, or there is injury, chest pain, a seizure lasting more than a few seconds, or a fall with a head strike, follow emergency procedures. That is why medical staff are present for live procedures [source for medical presence: Wannemueller et al. 2018].
4. After recovery, review what happened calmly and treat it as information. Where safe, go back to a slightly easier step in the same session so the session does not end on avoidance.
- The CCI sheet describes another manoeuvre: head below the knees for 30 s, then sit up and tense. It is not part of the Öst protocol [uncertain]. [synthesis] Prefer lying down with legs raised, because sitting up suddenly can bring back light-headedness.
Example language (illustrative): "You fainted for a few seconds. That's the reflex we talked about, and you're safe. Stay lying down and squeeze your legs for me. When you're ready, we'll take a step back and try again."
Watch for: shame or fear of repeating; any feature suggesting non-vasovagal syncope, which means medical review before continuing.

4.11 Maintenance programme

Purpose / when: At the end of treatment. Keeps gains and maintains the skill for future procedures.
Steps:
1. Write a plan with the client: continued self-exposure in daily life (e.g., watching medical TV, looking at injury images, being present when others have minor injuries, becoming a blood donor if appropriate), plus booking the procedures they had avoided [source: maintenance programme reported as part of Öst's AT in secondary descriptions [uncertain on content]; Nieto Centeno & Mas Hesse 2002 case became a registered donor].
2. Rehearse tension a few times before each planned medical visit [synthesis].
3. Schedule follow-up contact (the case studies used follow-ups at 4–12 months).
Example language (illustrative): "Over the next few months your job is to keep meeting blood and needles on purpose, so your body keeps learning this is safe."
Watch for: creeping avoidance; a long gap before the next real procedure. Suggest a booster practice the week before.

4.12 One-session (compressed) format

Purpose / when: When access, travel or motivation favour one long session, e.g., before an urgent procedure. Hellström et al. (1996) found one session about as effective as five.
Steps: In one extended session: assessment summary and rationale; tension training until it is done correctly; early-cue training; graded exposure with tension up the hierarchy, to the highest step that is safely possible; then a home practice and maintenance plan [source: Wannemueller et al. 2018 summary of Hellström et al. 1996; their group version used about 160 minutes total: training about 40 min, then picture, video and live blood-draw exposure]. The exact session length and sequence of the Hellström version were not confirmed [uncertain].
Example language (illustrative): "We'll spend today learning the skill and then use it, step by step, with the real thing, ending wherever you've got to safely."
Watch for: fatigue; the skill being under-practised before high-risk items. Build in rehearsal cycles throughout.

4.13 Tension-only variant

Purpose / when: A research comparison condition in Öst, Fellenius & Sterner (1991). It teaches the tension skill without planned applied practice during exposure. It was reported as effective, but it is not the recommended default [source: Div 12 reference list; Wannemueller et al. 2018 on Ayala et al. 2009]. Detailed procedure is [uncertain].
Steps / language / watch for: as 4.3–4.4. [synthesis] Consider it only when structured exposure cannot be arranged, and encourage self-exposure anyway.

4.14 Disgust-focused extension (add-on, not part of Öst AT)

Purpose / when: When strong disgust, rather than fear, drives avoidance or faintness. Disgust may fade more slowly with exposure.
Steps: Add hierarchy items aimed at disgust (bodily fluids, gore, 'animal reminder' stimuli). Rate disgust separately from fear. Stay longer and repeat more often, because fear often falls faster than disgust [source: Chapman & DeLapp 2013 citing Olatunji et al. 2006, 2007; procedural detail [synthesis]].
Example language (illustrative): "On a 0–100 scale, how scared are you right now? And separately, how disgusted?"
Watch for: high disgust ratings that are not falling. Extend exposure rather than moving on.

4.15 Cognitive work within wider CBT packages (add-on)

Purpose / when: When catastrophic beliefs (e.g., 'I'll faint and die', 'they'll think I'm pathetic') or anticipatory worry block engagement.
Steps: Identify the thoughts, check the evidence, and treat beliefs as hypotheses to test during exposure; self-instructions can address anticipatory thoughts [source: Chapman & DeLapp 2013, session 3; Navarrete López & Rando Hurtado case]. These are not part of the Öst & Sterner AT procedure.
Example language (illustrative): "What do you predict will happen when the nurse puts the tourniquet on? Let's write it down and see."
Watch for: cognitive work turning into a way to avoid exposure.

5. Handling problems

The AT sources say little about troubleshooting. Unless a source is tagged, the guidance below is [synthesis].

Headache from tensing. Often reported as a side effect of applied tension in clinical handouts, but not described in the sources [uncertain]. Response: reduce the force of tension (firm, not maximal), check the client is not holding their breath or clenching their jaw and face, and spread practice through the day. If headaches persist or are severe, pause and check blood pressure and medical status.
Faints despite tension. Check timing first: most failures come from starting too late. Move the trigger cue earlier (4.5) and rehearse cycles before the stimulus appears. Check technique: big muscles, legs included, held long enough to feel facial warmth. Step down the hierarchy and use smaller increments. Use reclined seating. Repeated faints at low steps, or faints with atypical features, mean medical review.
No warning signs before fainting. Use a pre-emptive schedule: continuous tension cycles from just before the stimulus and throughout. Monitor visible signs (pallor, sweating, slumping) yourself and prompt. Practise with low-intensity stimuli to help the client detect subtler cues.
Overwhelm or panic during exposure. Separate fear arousal from the drop (4.5). Reassure the client that a racing heart is not the fainting phase. Keep the client in the situation at a manageable step, lowering intensity (smaller image, distance, still instead of video) rather than stopping. If the client stops, re-enter as soon as possible at a lower step.
Over-relaxing after release. The client slumps or goes 'floppy'. Remind them of the 'back to normal, not relaxed' principle [source: Between Sessions 2018; Chapman & DeLapp 2013]. Shorten release periods and keep the eyes open and posture upright.
Using tension as avoidance. The client tenses constantly to blank out the stimulus or looks away. Tension is for the drop signs, and attention stays on the stimulus. Ask what they are looking at, and fade continuous tension as fear drops.
Non-adherence to home practice. Find the barrier (forgetting, embarrassment, fear of fainting while alone). Link practice to daily routines, allow practice with someone nearby [source: Between Sessions 2018], cut the session to fewer cycles rather than skipping, and review the log at the start of every session.
Refusal or reluctance to start exposure. Revisit the cost-benefit of avoidance, especially upcoming medical needs [source: Chapman & DeLapp 2013 used a cost-benefit discussion]. Offer a lower first step, such as a cartoon or drawing of a needle [source: CCI sheet]. Give the client control over pace and pausing.
Stuck (distress not falling). Check for hidden avoidance (looking away, distraction, mental escape), sessions that are too short, or steps that are too large. Assess disgust separately and extend exposure if it dominates (4.14) [source for disgust: Chapman & DeLapp 2013].
Faintness triggered by psychoeducation. Make materials less graphic, seat the client, and start tension training before showing any blood images [source: Wannemueller et al. 2018].
Rupture: the client feels pushed or embarrassed after fainting. Name it directly and normalise the reflex. Take responsibility for pacing if you moved too fast, then agree the next step together. Ask for feedback at the end of each exposure session.
Medical complications or comorbidity. If the client has heart, blood-pressure or neurological conditions, or takes medicines affecting heart rate or blood pressure, get medical advice before tension or high-risk exposure. In pregnancy, coordinate with the obstetric team. Pure needle fear without fainting can use standard exposure without AT. Panic disorder or medical health anxiety beyond BII triggers needs its own treatment components [source: Chapman & DeLapp 2013 addressed broader medical anxiety].
Pain-driven needle fear. Some needle avoidance is driven by pain rather than faintness. Discuss pain-reduction options with the medical team; the CCI hierarchy includes blood draws with numbing cream as an intermediate step [source: CCI sheet]. Keep the needle arm relaxed (4.9).
Real-world procedure is urgent. Use the one-session format (4.12), run at least one supervised rehearsal, brief the medical staff, and ask for the procedure to be done lying down.
Relapse after treatment. Return to home practice and self-exposure, and book a booster session before the next medical procedure (4.11).

Sources

Sources:

Further reading (not drawn on): the PMC case study (PMC4346072). Content attributed to the primary papers below comes from the secondary sources above [uncertain].