Focusing on the "what ifs": A practical guide to worry exposure

by Joye C. Anestis

The empirically-supported treatment for pretty much any anxiety disorder involves some sort of exposure.  For obsessive-compulsive disorder, it might be exposure to germs.  For panic disorder, exposure to, say, hyperventilation.  For PTSD, exposure to a traumatic memory.  And so on.  But how do you construct an exposure session when an individual fears something which hasn't happened, is often unlikely to happen, and can't be made to happen in therapy (i.e., worries about a hypothetical situation)?  Something like worrying that if your husband isn't home by 5:15, he must have gotten into a fatal car wreck, or worrying about what would happen if you began having financial problems, even if there is no indication that this is imminent.  Constructing exposures for such worries can be a bit intimidating...but a new article in Cognitive and Behavioral Practice offers up a succinct summary to help guide therapists through worry exposure.  In this article, authors Colin van der Heiden and Erik ten Broeke note that worry exposure, a type of imaginal exposure, was developed by Craske, Barlow, and Leary (1992; here's a link to the most recent edition of this manual: Mastery of Your Anxiety and Worry).  The authors first  offer some theoretical background and a succinct explanation of the rationale behind worry exposure (the provision of which is always the first step in any exposure technique).  Then they describe the five steps of worry exposure as:

1. "Selecting the worry situation to which a patient will be exposed": The authors recommend asking patients to stop their activities at set times during the day and write down whatever they are worrying about.  Patients should also be taught the difference between worries that are amenable to problem-solving (usually involving current or actual problems) and worries that are not (unproductive worry about hypothetical situations).  Worry exposure is designed to confront those worries that cannot be addressed via problem-solving.  Although the authors don't mention it, often once a list of fears is compiled, clients are asked to rank the fears in order to ascertain which are the most concerning.
2. "Identifying the most feared expectation": Once a situation is identified, the client is asked to state the worst possible outcome from the situation.  In order to assist with this, the therapist might ask a series of "what if" questions to each of the client's responses (sometimes referred to as the downward arrow technique), asking "...and if this actually happens, what will happen next?" until the patient can no longer come up with an answer.
3. "Conjure up an image of the most feared expectation": After the most feared expectation is identified, clients are asked to conjure up a vivid mental image of it and hold it in their mind for 25 minutes (other descriptions I've read say to hold it until client anxiety decreases by at least half).  They are not allowed to try to stop worrying, to distract themselves, or to try to neutralize the image.  The whole point of exposure is to experience unpleasant sensations so that clients attenuate to these sensations.
4. "Think of alternative explanation or outcomes": After the exposure is completed, clients are asked to think of and write down as many alternative outcomes or explanations for the feared situation as possible.  They will generally be able to realize that the likelihood of the feared outcome is slim and/or that, if it were to happen, it would not be as terrible as they imagined.
5. "Evaluation": In the next therapy session, the exposure is evaluated.  Things to discuss include: did feelings change during the exposure?  If so, in what way?  Are the alternative outcomes plausible?

It generally takes a little practice for both client and therapist to become facile with this technique.  To aid therapists further, the authors go through some common obstacles to this technique, as well as suggested solutions.  When done correctly, worry exposure can be very helpful with some clients, but there is a whole host of techniques to try for chronic worry (e.g., worry time, cognitive restructuring).  Check out our online bookstore for more resources for treating worry:

• Mastery of Your Anxiety and Worry (MAW): Therapist Guide (Treatments That Work)
  

• Mastery of Your Anxiety and Worry: Workbook (Treatments That Work)
  

• The Worry Cure: Seven Steps to Stop Worry from Stopping You

• Anxiety Free: Unravel Your Fears Before They Unravel You

Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.