The role of anxiety control strategies in imaginal exposure

Abstract

Although much has been written about in vivo exposure procedures and the specific parameters that either optimize or reduce its effectiveness, research on a closely related treatment strategy-imaginal exposure-currently lags behind, which is somewhat paradoxical considering that one of the first clinical applications of exposure was systematic desensitization, an imagery-based procedure (Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford University Press). In this chapter, we review current procedures for imaginal exposure with a specific emphasis on recommendations that are currently in place with regard to the use of anxiety control strategies, and discuss whether such recommendations are empirically justified. Of particular interest is the question of whether engagement in anxiety control strategies during mental imagery hinders or facilitates imaginal exposure. In the first part of the chapter, we will review the theories that underlie exposure procedures: (1) emotional processing theory (Foa & Kozak (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35; revision, Foa, Huppert, & Cahill (2006). Emotional processing theory: An update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 3–24). New York: Guilford Press), a theory that suggests that emotional activation and habituation are necessary ingredients in exposure; and (2) the “belief disconfirmation” theory (Salkovskis, Clark, Hackmann, Wells, & Gelder (1999). An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 559–574), a theory that suggests that disconfirmation of erroneous, fear-related beliefs is central to the effectiveness of exposure. Next, we will introduce the notion of anxiety control strategies, after which we will review the ways in which anxiety control strategies are handled in current in vivo exposure protocols, as a prelude to our discussion of imaginal exposure. Importantly, we will review, and evaluate the evidence for, the recommendations that are typically made with regard to anxiety control strategies in in vivo exposure. In the second part of this chapter, we will describe current imaginal exposure procedures for PTSD and GAD and will highlight recommendations that are made with regard to anxiety control strategies. We will discuss whether such recommendations are warranted based on the extant empirical literature.