14

Approaches to Common Obstacles in the Exposure-Based Treatment of

Obsessive-Compulsive Disorder
J o n a t h a n S. A b r a m o w i t z , M a y o Clinic
M a r t i n E. F r a n k l i n a n d S h a w n P. C a h i l l , University o f P e n n s y l v a n i a School o f Medicine
Treatment manuals have proven extremely useful in implementing exposure and ritual prevention (EX/RP) with patients with
obsessive-compulsive disorder (OCD). Nevertheless, treatment manuals cannot possibly attend to all possible situations encountered
in therapy, especiaUy with OCD patients who have such a diverse range of presentations. In this article we address four commonly encountered issues not explicitly described in the widely used EX/RP treatment manuals, lqrst, we offer suggestions on how to help patients understand their OCD symptoms in ways that fit into the theoretical framework of the treatment procedures. Second, we address
how to manage excessive reassurance-seeking behavior that is often obse~-oed in patients with particularly severe symptoms. Third, we
describe the importance of consistent exposure during (and after) treatment. Fourth, we discuss clinical decision-making regarding
the implementation of dtual prevention.

EYER AND COIJJ~AGUES' (Meyer, 1966; Meyer &

Levy, 1973) early reports on the benefits o f exposure a n d ritual p r e v e n t i o n (EX/RP) for what is now
known as obsessive-compulsive d i s o r d e r (OCD) generated considerable interest in this form of treatment. OCD
was at the time c o n s i d e r e d highly refractory to available
psychotherapies. Therefore, the a p p a r e n t success of E X /
RP offered new h o p e that p r o c e d u r e s based on learning
principles could be used to r e d u c e these symptoms. Since
then, n u m e r o u s studies have s u p p o r t e d the efficacy of
E X / R P (e.g., Lindsay, Crino, & Andrews, 1997), with substantial short- a n d long-term symptom r e d u c t i o n for the
vast majority o f patients who receive it (Foa & Kozak,
1996; Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000).
Given that E X / R P is now an empirically s u p p o r t e d treatm e n t for OCD, a n d designated by the APA Division 12
Task Force on P r o m o t i o n a n d Dissemination o f Psychological Procedures as a "well-established" treatment (Chainbless et al., 1998), attention has focused m o r e recently on
how to make it m o r e widely available (Greist, 2000).
T r e a t m e n t manuals, c o n s i d e r e d by many experts to be
essential to o u t c o m e research studies (Foa & Meadows,
1997), are used to p r o m o t e the standardization of therapy p r o c e d u r e s across therapists a n d patients. Optimally,
manuals should d e l i n e a t e the essential principles o f treatm e n t a n d provide clinicians with session-by-session procedural guidelines. T h e challenge in developing such a
m a n u a l is to specify abstract principles o f t r e a t m e n t in
sufficient detail that they can be a p p l i e d to a variety of

Cognitive and Behavioral Practice 10, 1 4 - 2 2 , 2003

1077-7229/03/14-2251.00/0
Copyright 2003 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.

patients, but not in so m u c h detail that the m a n u a l becomes too c u m b e r s o m e . This is an especially relevant
issue in the treatment of OCD as this disorder is characterized by exceptional heterogeneity. I n d e e d , no t r e a t m e n t
m a n u a l could adequately address the i m p l e m e n t a t i o n of
E X / R P across the countless possible presentations of OCD
(e.g., themes of obsessions, compulsions, a n d avoidance
behaviors). In this article, we p r e s e n t some clinically derived suggestions for h a n d l i n g c o m m o n l y e n c o u n t e r e d
obstacles in the t r e a t m e n t o f OCD that may n o t be explicitly described in widely used E X / R P t r e a t m e n t manuals
(e.g., Kozak & Foa, 1997).
We begin by offering suggestions on how clinicians can
help patients to u n d e r s t a n d their obsessive-compulsive
symptoms in ways that fit into the conceptual framework
o f the E X / R P t r e a t m e n t procedures. We find that patients come to therapy with a wide range o f thoughts a n d
beliefs (some useful and others not so useful) a b o u t
themselves, psychotherapy, a n d their disorder. Compliance with t r e a t m e n t r e c o m m e n d a t i o n s can be e n h a n c e d
when patients master the f u n d a m e n t a l theoretical tenets
o f therapy. Second, we address how to m a n a g e excessive
reassurance-seeking behavior that is often observed in patients with particularly severe symptoms. Offering unrealistic guarantees of safety d u r i n g e x p o s u r e can sabotage
such exercises, leading to a t t e n u a t e d outcome. Third, we
describe the i m p o r t a n c e o f consistent e x p o s u r e d u r i n g
(and after) treatment, a n d differentiate between two forms
of practice: that which is specifically assigned to the patient by the therapist ( " p r o g r a m m e d " exposure), a n d that
which involves m a k i n g decisions to c o n f r o n t obsessional
situations as they arise in everyday life ("lifestyle" exposure). Finally, we discuss clinical decision-making regarding the i m p l e m e n t a t i o n o f ritual prevention. M t h o u g h

Treatment of OCD
c o m p l e t e abstinence from compulsive ritualizing is the
ultimate goal, it may be necessary in some instances to
i m p l e m e n t ritual p r e v e n t i o n o n a m o r e g r a d u a l basis
to minimize failures a n d reinforce compliance.

Psychoeducation
Recent E X / R P t r e a t m e n t manuals (e.g., Kozak & Foa,
1997) d e s c r i b e an i n f o r m a t i o n - g a t h e r i n g / t r e a t m e n t p l a n n i n g phase d u r i n g which the therapist collects data
on the patient's specific fear cues, rituals, a n d avoidance
patterns. It is also d u r i n g this phase that a hierarchy o f situations to be c o n f r o n t e d d u r i n g e x p o s u r e (i.e., the treatm e n t plan) is collaboratively developed. To design a useful t r e a t m e n t plan, it is necessary for the therapist to
u n d e r s t a n d the functional relationships a m o n g the patient's idiosyncratic obsessional, compulsive, a n d avoidance symptoms. However, we have f o u n d that many OCD
patients themselves do n o t u n d e r s t a n d these functional
relationships very well, a n d h e n c e have a difficult time
identifying subtle symptoms that are necessary to address
in t r e a t m e n t (e.g., subtle mental rituals). Patients may
also be unaware that various facets o f OCD, such as logical errors in thinking, serve to maintain their symptoms.
Awareness o f these m o r e subtle aspects o f OCD can often
e n h a n c e the patient's ability to grasp the core theoretical
basis of their t r e a t m e n t a n d thereby get the most benefit
from E X / R P procedures. Given p a t i e n t heterogeneity, it
is difficult in an OCD t r e a t m e n t m a n u a l to clearly explicate how to h e l p patients b e c o m e aware of the disorder's
subtleties, yet clinically this very process may set the stage
for successful outcome. In o u r clinics, we often appeal to
the vast research literature on OCD symptoms to enlighten patients a b o u t such processes. We have observed,
in b o t h clinical a n d research settings, that such educational efforts may help patients to b e t t e r c o m p r e h e n d
the rationale for using EX/RP, l e a d i n g to b e t t e r compliance a n d o u t c o m e (Abramowitz, Franklin, Zoellner, &
DiBernardo, 2002). Below, we describe the psychoeducational p r o c e d u r e s we most c o m m o n l y use with patients.

Normality of Intrusive Thoughts

Patients with OCD are often u n d e r the impression
that they have s o m e t h i n g wrong with their mind, or they
are "going crazy" because of their u n w a n t e d thoughts
(e.g., "I m i g h t rape my daughter"). T h e i r fears often concern e n g a g i n g in h a r m f u l behavior, i n c l u d i n g the behavior o f thinking "bad" thoughts. However, findings from
research studies suggest that u n w a n t e d thoughts are a
n o r m a l a n d universal experience: 90% of the general
p o p u l a t i o n , even those without OCD, r e p o r t e d these
kinds o f thoughts (e.g., R a c h m a n & de Silva, 1978; Salkovskis & Harrison, 1984). R a c h m a n a n d de Silva (1978),
for example, f o u n d that mental h e a l t h professionals

could n o t distinguish between the c o n t e n t o f intrusive

thoughts o f OCD patients a n d those o f nonpatients.
W h e n patients express h o r r o r over the c o n t e n t o f their
intrusions, we often describe this study a n d even review
the list o f "normal" obsessional thoughts p r e s e n t e d in the
p u b l i s h e d article. We also e n c o u r a g e therapists to share
their own intrusive thoughts with patients to f u r t h e r normalize this p h e n o m e n o n .
L e a r n i n g that u n w a n t e d thoughts are a c o m m o n phen o m e n o n , r a t h e r than the p r o d u c t of an "inherently evil
p e r s o n ' s mind," often comes as a relief to patients, who
can then b e g i n to see their p r o b l e m (and themselves) as
m u c h less threatening. F r o m this i n f o r m a t i o n a b o u t normative functioning it follows that r e d u c i n g the frequency
a n d intensity o f obsessions a n d the distress they cause,
r a t h e r than eliminating u n w a n t e d thoughts altogether, is
the goal of EX/RP. This knowledge m i g h t also h e l p patients to refrain from neutralizing behaviors (e.g., compulsions, avoidance) that paradoxically m a i n t a i n distress
associated with obsessions.

The Thought Suppression Paradox

Being terrified of their intrusive, upsetting thoughts
a n d ideas, OCD patients often develop habits o f attempting to force u n w a n t e d thoughts o u t o f their mind, a process k n o w n as thought suppression. However, r e s e a r c h
suggests that trying to suppress thoughts ( u n d e r some
circumstances) results in an increase in the frequency o f
that t h o u g h t (for a review, see Abramowitz, Tolin, &
Street, 2001). F o r patients who are unaware o f this paradoxical effect o f t h o u g h t suppression, the inability to suppress may be extremely scary, l e a d i n g to f u r t h e r m a l a d a p tive beliefs (e.g., "My m i n d is out of control," "Maybe I
want it to h a p p e n " ) that m a i n t a i n m i s i n t e r p r e t a t i o n s o f
intrusive thoughts.
For the therapist, it may be useful to discuss the negative effects of suppression attempts with patients. O n e
helpful way of d e m o n s t r a t i n g this p a r a d o x is to e n g a g e
the p a t i e n t in the following b r i e f e x p e r i m e n t :

"I'd like you to try not to think o f a p i n k e l e p h a n t

for three minutes. You can think o f anything else
you want, b u t whatever you d o , j u s t d o n ' t t h i n k of a
p i n k elephant. Okay? Start when I tell you to, a n d
raise your h a n d if you h a p p e n to think o f a p i n k
elephant..."
Invariably, the patient will have pink e l e p h a n t thoughts
a n d a d m i t that it is impossible to suppress t h e m fully (the
authors have never h a d this e x p e r i m e n t fail!). Following
the e x p e r i m e n t , the p a t i e n t can be asked a b o u t how this
p h e n o m e n o n applies to their OCD symptoms. Such a discussion should focus on how thought suppression attempts
are unnecessary because thoughts are not inherently dangerous. However, attempts to suppress are d o o m e d to fail

15

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Abramowitz et al.
a n d t h e r e f o r e e x a c e r b a t e feelings that the d r e a d e d
t h o u g h t s are u n c o n t r o l l a b l e , repetitive, or the sign o f a
d a n g e r o u s or p e r v e r t e d mind. In addition, it is i m p o r t a n t
to p o i n t out that the m o r e effort the patient puts into
trying to c o n t r o l o r suppress, the m o r e the u n w a n t e d
thoughts will c o m e up. Giving extra attention to such
t h o u g h t s also s t r e n g t h e n s the b e l i e f that the t h o u g h t s
are threatening: After all, why else would s o m e o n e go
t h r o u g h the trouble to try to dismiss their thoughts?
T h e exercise d e s c r i b e d above, a n d the knowledge that
intrusive thoughts o c c u r normally a n d are not dangerous, leads nicely into p r e s e n t i n g a c o h e r e n t rationale for
imaginal exposure. In imaginal exposure, patients are instructed to purposely c o n f r o n t their u n w a n t e d thoughts
by e l a b o r a t i n g on t h e m in o r d e r to weaken the connections between such thoughts a n d anxiety. I n d e e d , these
thoughts themselves are not harmful a n d the associated
anxiety will dissipate with r e p e a t e d practice, especially as
the feared c o n s e q u e n c e s continually fail to occur in reality. We often use m e t a p h o r s , such as the following, for
imaginal exposure: Imaginal e x p o s u r e is very much like
weight training for athletes. Both require c o m p l e t i o n o f
exercises that are above a n d b e y o n d what one m i g h t enc o u n t e r on the playing field o r in real life, such as lifting
large barbells in the case o f the baseball player, or elaborating on a scenario in which c o n t a m i n a t i o n leads to serious h a r m for the OCD patient. At the same time, completion o f these difficult exercises invariably strengthens the
a t h l e t e / p a t i e n t to do what needs to be d o n e and increases the chances o f a positive outcome. For the athlete
it is r u n n i n g , batting, etc., a n d for the OCD patient it is allowing the s p o n t a n e o u s intrusions to linger while simultaneously refraining from any neutralizing behavior.

Thought-Action Fusion
Patients with OCD often make errors in the ways they
appraise u n w a n t e d (but harmless) obsessional thoughts.
T h e cognitive theory o f e m o t i o n a l disorders (e.g., Beck,
Rush, Shaw, & Emery, 1979) posits that these errors lead
to the e x t r e m e distress associated with the thoughts a n d
the urges to ritualize, avoid, o r thought-suppress to escape from distress. A specific logical e r r o r that is often
observable in people with OCD is thought-actionfusion (TAF).
First d e s c r i b e d by Shafran, T h o r d a r s o n , a n d Rachman,
(1996), TAF refers to the mistaken belief that thoughts
are equivalent to actions. I n d e e d , if a person with OCD
believes that h e r thoughts a b o u t yelling curse words in
c h u r c h are the moral equivalent o f actually d o i n g so, she
will initiate efforts to dismiss o r neutralize this thought.
Similarly, if a m a n with intrusive u n w a n t e d thoughts of
h u r t i n g his child believes that having such thoughts will
increase the probability that he will take such action, he
will be likely to e m p l o y similar ritualistic or avoidance behaviors. A goal o f E X / R P is to d e m o n s t r a t e that thoughts

(even disturbing a n d repetitive ones) d o n o t pose realistic threat. T h a t is, thinking a b o u t s o m e t h i n g is a purely
mental event, which, alone, can n o t directly cause something b a d to h a p p e n in the world.
A discussion o f the TAF fallacy is often useful in identifying a n d b e g i n n i n g to modify this mistake in affected
patients. F o r example, G o r d o n was a college-aged p a t i e n t
who h a d u n w a n t e d thoughts a b o u t stabbing others. H e
avoided using knives a r o u n d o t h e r p e o p l e a n d b e c a m e
convinced that it was only a m a t t e r of time before he lost
control a n d stabbed his best friends. As is the case with
m a n y OCD patients with aggressive obsessions, G o r d o n
was a gentle y o u n g man who h a d no history o f violence o f
any kind. To help G o r d o n identify this TAF mistake, he
was asked to t h i n k very h a r d a b o u t s t a n d i n g u p o u t o f
his chair while trying to r e m a i n seated. G o r d o n was instructed to visualize standing up, pray a b o u t standing,
a n d even say out loud, "I want to stand up." O f course,
G o r d o n d i d n o t stand u p d u r i n g the e x p e r i m e n t . This exercise can be used to illustrate how p e o p l e have to consciously decide to act, a n d that their thoughts d o n o t automatically translate to impulsively e n g a g i n g in i m p r o p e r
behaviors. This (and o t h e r similar exercises) often provides a robust d e m o n s t r a t i o n o f the logical error, a n d patients frequently feel m o r e willing to e n g a g e in E X / R P
exercises that help to modify dysfunctional beliefs a b o u t
the relationship between unwanted thoughts a n d actions.
G o r d o n , himself, g e n e r a t e d a particularly useful exposure that he carried o u t successfully: using a knife while
purposely thinking a b o u t stabbing the p e r s o n sitting n e x t
to him.
Sometimes, OCD patients r e p o r t fears that they will be
responsible for s o m e t h i n g terrible o c c u r r i n g (e.g., an accident) simply because they had a t h o u g h t a b o u t such an
occurrence. O n e patient, Norah, feared that h e r thoughts
of h e r h u s b a n d dying in a plane crash would increase the
likelihood o f such a tragedy. N o r a h f o u n d herself having
such terrifying ideas whenever h e r h u s b a n d traveled, a n d
would s p e n d hours paralyzed, e n g a g e d in attempts to
neutralize the thoughts (i.e., "canceling t h e m out" in h e r
mind) and praying that such an accident would n o t occur.
She also tracked the progress o f h e r husband's plane on
the W o r l d W i d e Web, a n d p h o n e d the d e s t i n a t i o n repeatedly to be sure he h a d arrived safely. O n questioning,
N o r a h stated that she felt "responsible for having b a d
thoughts a b o u t the plane."
In a d d i t i o n to a discussion a b o u t the n o r m a l c y o f intrusive upsetting thoughts, N o r a h was asked to c o n d u c t a
b r i e f e x p e r i m e n t in the session that i n c l u d e d looking o u t
the window a n d purposely t h i n k i n g a b o u t specific cars on
the r o a d crashing. At o n e point, a p e d e s t r i a n crossed the
street a n d Norah, with the therapist, wished for this individual to be struck (fortunately, these mishaps d i d n o t
occur!). This demonstration nicely illustrated the mistake

T r e a t m e n t of OCD

she was m a k i n g a n d f u r t h e r o p e n e d the d o o r to working

o n this p r o b l e m using m o r e difficult e x p o s u r e exercises.
As with many patients, N o r a h c o u l d think a b o u t accidents to strangers fairly easily; yet when she was asked to
t h i n k a b o u t h e r h u s b a n d , the task elicited high levels o f
anxiety. In fact, she r e s p o n d e d to the i d e a by asking why
she would ever want to purposely think o f such a thing.
Often patients resist e x p o s u r e exercises that seem (to
them) riskier than what "normal p e o p l e " would do. In
this case, the therapist should p o i n t o u t that the treatm e n t exercises are n o t d e s i g n e d on the basis o f what
most p e o p l e would do, b u t instead (as we describe above)
are designed to weaken unrealistic beliefs a b o u t d a n g e r
a n d c o n n e c t i o n s between harmless thoughts a n d anxiety.
T h e t e n d e n c y for patients with OCD to show TAF in some
specific situations b u t n o t others is frequently observed
a n d speaks volumes a b o u t the n a t u r e of this condition.
I n d e e d , patients should be m a d e aware o f the fact that
they are willing a n d able to use g o o d logic in certain situations b u t n o t in others.
Intolerance for Uncertainty

A n o t h e r logical e r r o r p r e s e n t in OCD is the intolerance for uncertainty. Indeed, some compulsive rituals can
be c o n c e p t u a l i z e d as attempts to gain 100% certainty in
feared situations. C o n s i d e r the w o m a n who washes h e r
l a u n d r y three times fearing that the first two washes d o n ' t
remove all of the germs, o r the m a n who rereads his letters (even o p e n i n g sealed envelopes) over a n d over to be
completely certain he d i d n o t write anything obscene by
mistake. It is as if patients believe that in the absence of
absolute certainty, d a n g e r o r h a r m is likely (in contrast,
most p e o p l e assume a situation is safe in the absence o f
clear d a n g e r cues). Interestingly, this bias is only a p p l i e d
in certain situations: those that are OCD-relevant. This
p h e n o m e n o n can be illustrated for patients using a b r i e f
d e m o n s t r a t i o n . We often ask patients who struggle with
uncertainty to tell us w h e t h e r o r n o t their spouse or pare n t (known to be living) is alive at that very m o m e n t . In
most instances (even if the p a t i e n t has obsessional fears
of relatives dying), patients automatically respond, "Of
course they're alive." T h e therapist then asks the m o r e
difficult question, "How d o you know for sure?" Patients
explain that they d o n ' t know f o r sure, b u t they assume
things are okay unless they find o u t otherwise.
Thus, a l t h o u g h patients have the ability to tolerate uncertainty when it comes to thoughts o f some tragedies,
they have difficulty d o i n g so in OCD-relevant situations,
particularly when the uncertainty is c u e d by intrusive obsessional doubts. It remains u n c l e a r as to w h e t h e r problems with uncertainty are a cause or effect o f anxiety o r
fear. However, the p h e n o m e n o n can be used therapeutically to p o i n t o u t how this mistake serves to maintain
OCD symptoms in terms o f urges to p e r f o r m compulsive

17

rituals in o r d e r to obtain reassurance. A discussion o f how

the p r o c e d u r e s o f E X / R P are d e s i g n e d to h e l p patients
feel m o r e c o m f o r t a b l e with uncertainty, a n d less like they
n e e d c o m p l e t e reassurance o f safety (as they are able to
do in non-OCD-related situations), is useful in "selling"
the cognitive-behavioral m o d e l of OCD a n d rationale for
treatment.
Psychoeducational p r o c e d u r e s such as those elabor a t e d u p o n above can be used at all points d u r i n g EX/RP.
D u r i n g the i n f o r m a t i o n - g a t h e r i n g phase it is often helpful to identify a n d discuss how logical mistakes are r e l a t e d
to OCD symptoms, a n d explain how E X / R P can be helpful in modifying these cognitive errors. This may serve to
normalize the symptoms a n d allow the p a t i e n t to recognize that the therapist u n d e r s t a n d s this seemingly "crazy"
or "bizarre" p r o b l e m . We inform patients that E X / R P requires an u n d e r s t a n d i n g the symptoms of OCD a n d the
conditions that maintain those symptoms, r a t h e r than an
u n d e r s t a n d i n g o f the initial causes the disorder. Thus,
these psychoeducational discussions also serve to reinforce this focus.
Awareness o f the cognitive biases discussed above also
helps the p a t i e n t identify when the errors are o c c u r r i n g
a n d how influential they can be. F u r t h e r m o r e , presenting these concepts in a way that is consistent with the rat i o n a l e for E X / R P allows the p a t i e n t to see how the treatm e n t p r o c e d u r e s can be used to modify these maladaptive
strategies. A n o t h e r excellent time to reiterate psychoeducational i n f o r m a t i o n is d u r i n g e x p o s u r e exercises while
the p a t i e n t is c o n f r o n t i n g f e a r e d situations a n d experiencing obsessional thoughts. Here, such discussions c a n
be used to reinforce new a n d m o r e functional m e t h o d s
o f h a n d l i n g obsessional doubts a n d fear-evoking situations. However, it is i m p o r t a n t that such psychoeducational efforts are n o t used to reassure the p a t i e n t o f safety.
I n d e e d , the issue o f providing reassurance often arises
when working with OCD patients, a n d t h e r e f o r e it is discussed below.

Providing

Reassurance

in EX/RP

Cognitive-behavioral conceptualizations o f OCD view

compulsive rituals as providing escape from anxiety o r
distress, thereby serving to m a i n t a i n c o n n e c t i o n s between obsessional stimuli a n d distress. In m a n y cases, the
distress is associated with doubts a n d u n c e r t a i n t y over
w h e t h e r or n o t a d r e a d e d o u t c o m e will occur (e.g., "Will
I get sick?" "Will it cause a fire?"). In large part, a goal o f
E X / R P is to teach p e o p l e with OCD to b e c o m e m o r e
c o m f o r t a b l e with an acceptable level of uncertainty. This
n e e d for a g u a r a n t e e a n d the tolerance for u n c e r t a i n t y
seem to vary across patients with OCD. Some patients
recognize their excessive d o u b t i n g a n d are willing to att e m p t to tolerate n o t knowing for sure a b o u t obsessionally

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Abramowitz et al.
feared outcomes. T h e ability to completely abstain from
compulsive rituals is often a g o o d indicator o f this important attribute. O t h e r patients, however, may have an extraordinarily difficult time n o t b e i n g reassured of safety.
T h e persistence o f rituals such as subtle checking, a n d
not-so-subtle question-asking, is often a sign of high levels
o f i n t o l e r a n c e for uncertainty.
To illustrate, we describe the particularly severe case o f
Joe, who h a d fears o f c o n t a m i n a t i o n from pesticides.
W h e n p l a n n i n g c o n f r o n t a t i o n with places that h a d been
sprayed with pesticides,Joe insisted that he a n d the therapist m e e t with an e x p e r t on pesticides to define what is a
safe level o f exposure. I n d e e d , J o e r e p o r t e d having previously sought such information, b u t said that he was unsatisfied with the qualifications o f the five o t h e r pesticide
"experts" he h a d interviewed. T h r o u g h o u t treatment, J o e
wrote copious notes a b o u t each fear-evoking situation
that arose between sessions (e.g., h e a r i n g s o m e t h i n g that
s o u n d e d like s o m e o n e spraying pesticides) a n d how he
h a n d l e d it. D u r i n g e x p o s u r e exercises, J o e asked fiequently for assurances from the therapist (e.g., "Are you
sure this is safe?" "Would you h o l d your baby or eat without washing your hands after d o i n g this?") a n d a t t e m p t e d
to e n g a g e in m o r e subtle forms of reassurance seeking
such as p e r f o r m i n g crude risk analyses a n d trying to recall the p e r c e n t o f b u g spray (parts p e r 100) that contains
the active ingredient.
Just like p e r f o r m i n g m o r e classic rituals such as washing a n d checking, these forms o f reassurance seeking interfere with progress in E X / R P because they prevent direct exposure to the actual feared situation, which involves
b e i n g u n c e r t a i n a b o u t the consequences. Patients with
OCD must learn to r e d u c e their fears of uncertainty and
urges for attaining certainty. Thus, attempts to gain reassurance are functionally equivalent to compulsive rituals
and should be eliminated. Howevm, excessive reassurance seeking must be h a n d l e d with caution because misc o m m u n i c a t i o n s can derail therapy. Below we describe
some useful ways to address these problems.

Appeals to Authority
It is most consistent with the principles of E X / R P for
patients to e n g a g e in e x p o s u r e exercises without having
to check with "experts" a b o u t the safety o f such tasks. Unnecessary reassurances of safety i m p i n g e on the match
between the patient's fear a n d the e x p o s u r e situation a n d
reinforce the (excessive) n e e d for such an o p i n i o n in
everyday life (which is n o t practical). Requests for such a
consultation should be c o n s i d e r e d a n d discussed in light
o f w h e t h e r o r n o t they will be helpful for moving the patient toward o v e r c o m i n g their n e e d for certainty. In some
instances, it may be useful to allow a single consultation
visit with an expert, for example, if d o i n g so would prevent the patient from d r o p p i n g out o f treatment. How-

ever, the therapist should supervise such a consultation to

ensure that excessive ritualizing does n o t take place. Furt h e r m o r e , the p a t i e n t should agree to ask only b r o a d
questions a b o u t risk since the goal o f such a consultation
is to establish guidelines a b o u t safety, n o t to inquire
a b o u t every possible situation that may arise. Such questions should be a g r e e d u p o n p r i o r to the m e e t i n g with
the expert, because patients will often want to inquire
a b o u t specific feared situations. If possible, this should be
p r e v e n t e d a n d patients should instead be taught that
l e a r n i n g the ability to apply j u d g m e n t a b o u t risk (rather
than know for sure a b o u t the probability o f h a r m ) in specific feared situations is a must for o v e r c o m i n g OCD. T h e
t r e a t m e n t of patients with scrupulosity (religious OCD
symptoms) often necessitates consultation with a religious authority to establish b o u n d a r i e s a b o u t what is a n d
what is not religious sin (Abramowitz, 2001).

Asking for Reassurance During Exposure

As we discussed above, the goal of E X / R P is to r e d u c e
the n e e d for absolute certainty without having to resort
to reassurance-seeking rituals. However, some patients
are particularly persistent at questioning the therapist to
tiT to gain assurance of safety, a n d have difficulty resisting
this behavior even d u r i n g e x p o s u r e exercises. In such instances, the first inclination may be to ease patients with
guarantees that they are n o t in any danger. However, this
u n d e r m i n e s the goal o f t e a c h i n g p a t i e n t s to live with
acceptable levels o f risk a n d uncertainty. O n the o t h e r
hand, it is not necessary to try to convince patients that
they are i n d e e d putting themselves at high risk for negative consequences. The most preferable response uses a
c o m p a s s i o n a t e a p p r o a c h , focusing on how e x p o s u r e s
are d e s i g n e d to evoke uncertainty. It is often useful to
explain to patients that a l t h o u g h e x p o s u r e exercises
p r e s e n t low risk, there can never truly be an absolute guarantee o f safety.
T h e occasional patient will persistently ask the same
questions again a n d again (perhaps in different ways),
because they are reassured by h e a r i n g the therapist say
that the risk o f h a r m is low. This is an instance in which
clinical j u d g m e n t is n e e d e d to assess w h e t h e r the function of the questioning truly is assurance seeking. A general rule to keep in m i n d is that questions a b o u t risk in a
given situation should be answered only once. A d d i t i o n a l
attempts to gain assurance should be p o i n t e d out to the
patient a n d addressed in an e m p a t h i c way, such as:
"It sounds like y o u ' r e feeling u n c o m f o r t a b l e and
are searching for that g u a r a n t e e right n o w - - a n d
that's your obsessional doubting. Since I already
answered that question, it would not be helpful for
you if I answered it again. T h e best way to stop the
obsessional doubts is for you to work on tolerating

Treatment of OCD

the distress a n d u n c e r t a i n t y . . . How can I h e l p you

to do that?"
Assurance seeking can also be m o r e subtle, such as a
patient's m a k i n g a s t a t e m e n t a b o u t a h o m e w o r k exposure they are p l a n n i n g ("Now that we've t o u c h e d the
trash bin, I ' m going to go h o m e a n d play with my 2-yearold") a n d t h e n scrutinizing the therapist's facial expression for signs o f concern. In such instances the therapist
should make inquiry o f the p a t i e n t as to w h e t h e r the
s t a t e m e n t constituted assurance seeking, a n d t h e n revisit
the rationale for n o t providing such assurances.
T h e authors have unfortunately w o r k e d with some individuals who were completely u n a b l e (or unwilling) to
resist persistent reassurance-seeking behavior in a n d between sessions. Because failing to refrain from seeking
assurance interferes p r o f o u n d l y with E X / R P (indeed, it
is equivalent to refusing to abstain from any o t h e r rituals)
a n d inevitably c o m p r o m i s e s o u t c o m e , therapy h a d to be
s u s p e n d e d in these cases. As addressed in t r e a t m e n t manuals, suspension is the last resort when patients refuse to
comply with treatment procedures. If this option is chosen,
it is i m p o r t a n t to convey in the most sensitive a n d caring
way why the therapist r e c o m m e n d s discontinuation o f
t r e a t m e n t at p r e s e n t (i.e., because the p a t i e n t is u n a b l e
to carry o u t the t r e a t m e n t p r o c e d u r e s in ways that would
be beneficial) a n d what alternatives m i g h t be available.

"Programmed" vs. "Lifestyle" Exposure

Practicing in-session (therapist-supervised) exposure
and carrying out exposure homework assignments are core
features o f most E X / R P programs. However, c o m p l e t i n g
only these p r e s c r i b e d assignments is n o t sufficient: Immediate a n d long-term i m p r o v e m e n t requires consistent
e x p o s u r e practice across a variety o f situations in o r d e r to
p r o m o t e generalization of learning. Whereas patients
usually grasp the n o t i o n o f ritual p r e v e n t i o n as m e a n i n g
abstinence from compulsive rituals, it is n o t always as
clear to t h e m that they must also practice "avoidance prevention." Some patients c o m p l e t e their assigned exposures a n d then p r o c e e d to use avoidance strategies between assignments, effectively d i s r e g a r d i n g the p u r p o s e
o f e x p o s u r e in the first place. Don, for example, comp l e t e d 2 hours o f assigned e x p o s u r e in which he h e l d his
shoes in his lap, b u t t h e n took precautions to avoid
t o u c h i n g his pants because they h a d b e e n in contact with
his shoes! Not surprisingly, Don's anxiety a b o u t shoes rem a i n e d high despite his reliable c o m p l e t i o n o f e x p o s u r e
a n d his refraining from rituals. A l o n g with continually
curtailing rituals, patients should be e n c o u r a g e d to engage in continual self-guided exposure. We suggest that
patients think o f E X / R P as l e a r n i n g a new lifestyle that is
conducive to gaining control over, r a t h e r than b e i n g controlled by, OCD.

!9

In o u r t r e a t m e n t p r o g r a m we have f o u n d that distinguishing between two categories o f t h e r a p e u t i c e x p o s u r e

helps patients to practice a p p r o p r i a t e responses to anxietyevoking situations that arise between sessions. W h e n treatm e n t p r o c e d u r e s are discussed with patients, we describe
" p r o g r a m m e d " e x p o s u r e as the systematic assignments
that are p r e s c r i b e d by the therapist for c o m p l e t i o n within
o r between sessions. These are usually written o n h o m e work forms given to patients on which to r e c o r d ratings
of subjective anxiety (SUDs) d u r i n g the exercise. "Lifestyle" exposure, on the o t h e r hand, is d e s c r i b e d as making choices to take advantage o f all possible o p p o r t u n i t i e s
to practice the new ways of r e s p o n d i n g (i.e., confronting
r a t h e r than avoiding). Patients are e n c o u r a g e d to be opportunistic a n d view potentially anxiety-evoking situations n o t as something to be avoided or e n d u r e d with great
distress, b u t instead as occasions to practice E X / R P a n d
work on f u r t h e r r e d u c i n g OCD symptoms. To this end,
we emphasize the choices that patients have to e i t h e r
c o n f r o n t o r avoid, a n d that each time an anxiety-evoking
situation is c o n f r o n t e d w i t h o u t a v o i d a n c e o r ritualistic
behavior, OCD is b e i n g w e a k e n e d . Alternatively, each
time a decision is m a d e to avoid a potential lifestyle exposure situation, the OCD symptoms may be s t r e n g t h e n e d .
Whereas the c o n c e p t o f lifestyle e x p o s u r e is usually
helpful, it is sometimes too m u c h to e x p e c t that patients
will c o n f r o n t all OCD-relevant situations f r o m the start
o f therapy. I n d e e d , until the p a t i e n t has c o m p l e t e d prog r a m m e d e x p o s u r e to the most difficult items o n the
stimulus hierarchy, patients may n o t be particularly successful with lifestyle e x p o s u r e to these items. If patients
raise this issue, therapists should be flexible by encouraging e x p o s u r e attempts in the "spirit" of treatment, while
u n d e r s t a n d i n g that c o n f r o n t a t i o n with m o r e difficult situations may at first be avoided. I n d e e d , if such lifestyle
e x p o s u r e to the most difficult situations has a l i k e l i h o o d
o f resulting in excessive ritualizing, the therapist may
c o n s i d e r proscribing activities that could l e a d to such naturalistic exposures until the p a t i e n t has h a d success with
p r o g r a m m e d e x p o s u r e to the relevant situations. T h e
p u r p o s e o f such t e m p o r a r y avoidance o f the most difficult items is to minimize violations of response prevention a n d prevent f u r t h e r s t r e n g t h e n i n g o f existing rituals.
As suggested by Kozak a n d Foa (1997), a collaborative
treatment plan that involves a (flexible) session-by-session
list o f e x p o s u r e situations can be used to d e t e r m i n e when
m o r e difficult situations will be confronted. As we will see
below, an analogous situation r e q u i r i n g flexibility also
exists with i m p l e m e n t i n g ritual prevention.

Implementing Ritual Prevention

D i s m a n t l i n g studies o f E X / R P have f o u n d that in
c o m b i n a t i o n with exposure, patients must curtail their

20

Abramowitz et al.
compulsive ritualizing in o r d e r to achieve m a x i m u m
short- a n d long-term benefit. In fact, there is a d e g r e e of
specificity between the t r e a t m e n t c o m p o n e n t s a n d OCD
symptoms, with e x p o s u r e resulting in a greater r e d u c t i o n
o f obsessional anxiety a n d ritual prevention resulting in a
greater reduction in time spent ritualizing (Foa, Steketee,
& Milby, 1980). However, the c o r r e s p o n d e n c e between
the e x p o s u r e a n d ritual prevention elements of treatm e n t with anxiety a n d time spent ritualizing is n o t perfect, in that e x p o s u r e alone can result in some r e d u c t i o n
in compulsions a n d ritual prevention can result in some
anxiety reduction. A meta-analysis also f o u n d that E X / R P
p r o g r a m s i n c o r p o r a t i n g complete ritual abstinence prod u c e d b e t t e r o u t c o m e s than d i d those e m p l o y i n g partial
ritual prevention (Abramowitz, 1996). Thus, ritual prevention is a critically i m p o r t a n t c o m p o n e n t of E X / R P
a n d the rationale for this p r o c e d u r e should be p r e s e n t e d
to the patient very early a n d reiterated t h r o u g h o u t the
course o f therapy. T h e rationale provided should e m p h a size that this p r o c e d u r e helps patients to learn that the
anticipated negative consequences o f e x p o s u r e do n o t
occur, leading to the realization that o n e does not n e e d
to ritualize to p r o t e c t themselves o r others from danger.
Kozak a n d Foa (1997) suggest the use of self-monitoring
forms on which patients r e c o r d any violations of ritual
prevention instructions.
However, the i m p l e m e n t a t i o n o f ritual prevention is
n o t always straightforward, a n d thus is sometimes misunderstood. Because it is generally self-governed (i.e., cond u c t e d by the p a t i e n t between sessions), p e r s u a d i n g the
client to choose n o t to ritualize is a necessary first step for
g o o d o u t c o m e s a n d u n d e r s c o r e s the n e e d to have patients set a goal o f complete, as o p p o s e d to only partial,
ritual abstinence. I n d e e d , experts suggest that partial ritual prevention is a fairly c o m m o n p r o b l e m in t r e a t m e n t
and, as i n d i c a t e d above, a potentially serious i m p e d i m e n t
to g o o d o u t c o m e (Kozak & Foa, 1997). Therapists are
e n c o u r a g e d to r e m i n d patients of the i m p o r t a n t role of
refraining from rituals, but also caution t h e m against excessive self-criticism f o u n d e d on unrealistic perfectionism as at least some violations o f response prevention are
b o u n d to occur. In such instances, patients should be
taught to c o u n t e r the occasional ritualizing with intentional re-exposure o r take some o t h e r m e a s u r e to "spoil"
the ritual. G o r d o n , for example, frequently e n g a g e d in
the ritual of saying o r thinking "God forbid" in o r d e r to
prevent terrible things from h a p p e n i n g to friends o r family. Because this ritual was so quick, easy to perform, a n d
socially acceptable, it was difficult for G o r d o n to consistently refrain from e n g a g i n g in it. H e was, however, able
to recognize when it h a p p e n e d and then spoil it by counterthinking "God willing" the terrible event should happen.
Given the relationship between ritual prevention a n d
eventual reduction of the frequency and intensity of OCD

symptoms, it would seem i m p o r t a n t to e n c o u r a g e patients to target c o m p l e t e abstinence early on in treatment. At times, however, this goal may be inconsistent
with that of systematic, g r a d e d e x p o s u r e using a hierarchy. I n d e e d , patients may have c h a n c e e n c o u n t e r s with
frightening stimuli, which evoke high urges to ritualize,
b u t which have n o t yet b e e n practiced in session. A related difficulty is that patients could b e c o m e d e m o r a l i z e d
if they feel overwhelmed, or think that they cannot achieve
c o m p l e t e ritual abstinence immediately. An alternative to
full ritual prevention is a graded a p p r o a c h in which ritual
prevention instructions parallel the progress up the exposure hierarchy, with the goal b e i n g c o m p l e t e ritual abstinence midway into treatment. Below, we illustrate the
use o f this a p p r o a c h for a patient with severe washing a n d
cleaning rituals who likely would have d i s c o n t i n u e d treatm e n t h a d the t h e r a p i s t insisted u p o n c o m p l e t e ritual
prevention from the start of therapy, as described in the
t r e a t m e n t m a n u a l (Kozak & Foa, 1997).
Lori was contamination-fearful, h a d clinically significant OCD since high school, a n d h a d e x p e r i e n c e d a
gradual worsening o f h e r symptoms over the last 5 years
such that h e r general functioning was largely impaired,
especially in n o n w o r k domains. To make matters worse,
Lori worked in a medical c o n t e x t in which h a n d washing
between patients was required, a n d she h a d ready access
to Betadine, an abrasive cleanser that she used with great
frequency both at h o m e a n d at work. She m a n a g e d to
function at work by wearing triple gloves, which went unc h a l l e n g e d by coworkers. Unlike most OCD patients with
c o n t a m i n a t i o n fears who worry a b o u t c o n t a m i n a t i o n
from the environment, the source o f c o n t a m i n a t i o n was
herself: Lori feared c o n t a m i n a t i n g others with h e r "negative essence" that was especially c o n c e n t r a t e d in the
lower half o f h e r body. As a medical professional she recognized that this c o n c e r n was illogical a n d u n f o u n d e d ,
yet she was so fearful o f the possibility o f h a r m i n g others
that she was entirely unwilling to take such a risk. T h e extent of avoidance a n d rituals was remarkable: At intake
Lori r e p o r t e d that she h a d n o t t o u c h e d the lower half o f
h e r body in 5 years without some sort o f b a r r i e r (e.g.,
glove) to prevent direct contact with h e r skin.
W h e n the rationale for voluntary ritual abstinence was
p r e s e n t e d in the first t r e a t m e n t session, Lori i m m e d i a t e l y
burst into tears, saying, "There's j u s t no way I can possibly
d o that." T h e therapist assured h e r that many p e o p l e feel
this way before b e g i n n i n g the therapy a n d that gradual
exposure to feared situations a n d thoughts would allow
for titration of anxiety; yet this i n f o r m a t i o n was only
mildly helpful. Lori correctly p o i n t e d out that once h e r
use o f barriers was eliminated, c o m p l e t e flooding would
ensue a n d she would then have to wipe herself after urinating a n d defecating, scratch itches, a n d dress herself
without any p r o t e c t i o n against c o n t a m i n a t i n g the u p p e r

Treatment of OCD

half o f h e r body a n d t h e n c o n t a m i n a t i n g o t h e r people.

A d d i t i o n a l discussion with the therapist f u r t h e r underscored the distance between h e r c u r r e n t f u n c t i o n i n g a n d
the desired ritual abstinence. Even at h o m e , she was
using abrasive cleaners, triple gloves, a n d e n g a g i n g in an
extensive l a u n d r y ritual that r e d u c e d h e r fears o f becoming c o n t a m i n a t e d by the lower half o f h e r b o d y a n d
s p r e a d i n g c o n t a m i n a t i o n with h e r hands.
T h e therapist believed that this p a t i e n t was correct in
h e r assessment a n d would be u n a b l e to negotiate this dramatic a d j u s t m e n t in h e r ritualized r o u t i n e without bec o m i n g overwhelmed. Thus, a revised ritual prevention
plan was contrived. A c c o r d i n g to this plan, she would
eliminate the third set o f gloves in the h o m e environm e n t after the first session a n d eliminate the s e c o n d pair
o f gloves at h o m e a n d the third set o f gloves at work after
session two. G r a d u a l removal o f rituals a n d avoidance
would c o n t i n u e until she was wearing n o gloves a n d
d o i n g no washing in h e r h o m e or work environment. Additionally, it was acceptable for Lori to use single gloves
after defecating a n d u r i n a t i n g until such time that these
items were c o n f r o n t e d o n the stimulus hierarchy. Only
after she h a d virtually r e f r a i n e d from rituals for two consecutive days were exposures to directly contacting skin
o n the lower half of h e r b o d y i m p l e m e n t e d .
T h e gradual nature o f the ritual p r e v e n t i o n schedule
would delay accidental exposures to items at the top of
the stimulus hierarchy, which the p r o t o c o l suggests
should be c o n f r o n t e d at the e n d o f the first week o f daily
therapist-assisted EX/RP. This is to ensure sufficient practice with these most difficult items within the 3Vz-week
time frame o f the t r e a t m e n t protocol. Again, r a t h e r than
b e i n g a hard-and-fast rule that must be h e e d e d regardless
o f circumstance, the stated goal o f r e a c h i n g the top o f
the hierarchy by the e n d o f the first week is derived from
the general principle o f leaving sufficient time a n d opp o r t u n i t y for h a b i t u a t i o n a n d cognitive change. This
gradual ritual prevention d i d necessitate a delay in reaching this highest item a n d r e q u i r e d additional h o m e w o r k
assignments in the final week to ensure h a b i t u a t i o n before the e n d o f the treatment. O n the o t h e r hand, it was
inconceivable to the p a t i e n t (and to the therapist) how
the top o f the hierarchy c o u l d possibly have b e e n addressed any e a r l i e r given the severity o f the p a t i e n t ' s
symptoms. At the e n d o f treatment, Lori told the therapist that she was p r e p a r e d to d r o p o u t o f E X / R P after the
first session u p o n h e a r i n g a b o u t the goal o f c o m p l e t e a n d
i m m e d i a t e ritual abstinence, a n d h a d c o m e to the s e c o n d
session only as a courtesy. U p o n h e a r i n g that this treatm e n t goal could i n d e e d be shifted, she e n g a g e d fully in
the treatment: She was highly c o m p l i a n t with in-session
exposure, c o m p l e t e d e x p o s u r e h o m e w o r k faithfully, a n d
was diligent in h e r a d h e r i n g to the revised ritual prevention p r o g r a m .

21

Conclusion
We have a t t e m p t e d to h i g h l i g h t several issues that may
c o n f r o n t therapists who are c o n d u c t i n g E X / R P using recent t r e a t m e n t manuals o n the topic (e.g., Kozak & Foa,
1997). O u r aim is to assist therapists in flexibly applying
these t r e a t m e n t p r o c e d u r e s to fit the needs o f individual
patients. We chose to focus first on p s y c h o e d u c a t i o n for
OCD, as we believe that the patient's u n d e r s t a n d i n g o f
the theoretical f o u n d a t i o n for the t r e a t m e n t sets the
stage for g o o d outcome. We t h e n shifted to several specific p r o b l e m s often e n c o u n t e r e d in clinical practice, yet
s e l d o m discussed in detail in t r e a t m e n t manuals. These
include curtailing assurance seeking, e n c o u r a g i n g patients to take advantage o f s p o n t a n e o u s o p p o r t u n i t i e s to
p u t the t r e a t m e n t principles into practice, a n d d e c i d i n g
when a n d how to adjust ritual p r e v e n t i o n instructions
with severely ill patients.
However, the topics we addressed are by no m e a n s exhaustive. T h e r e are countless o t h e r issues that arise in the
t r e a t m e n t o f OCD that may r e q u i r e tailoring o f manualized t r e a t m e n t p r o c e d u r e s , exercise o f s o u n d clinical
j u d g m e n t on a case-by-case basis, a n d an o p e n n e s s to
l e a r n i n g "on the fly" from patients we interact with. T h e
t r e a t m e n t o f OCD will be refined a n d i m p r o v e d with exp e r i m e n t a t i o n using novel a p p r o a c h e s to p r e s e n t i n g a n d
i m p l e m e n t i n g EX/RP. I n d e e d , m o r e r e c e n t t r e a t m e n t
manuals (e.g., Steketee, 1998) advocate the use o f cognitive therapy p r o c e d u r e s n o t explicitly d e s c r i b e d in previous E X / R P protocols. Research e x a m i n i n g the efficacy o f
these newly d e v e l o p e d a n d p r o m i s i n g p r o c e d u r e s is currently u n d e r way. Thus, we highly e n c o u r a g e f u r t h e r clinical case reports illustrating useful techniques for implem e n t i n g E X / R P that may n o t be d e s c r i b e d in the existing
t r e a t m e n t manuals.

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mayo.edu.

Received: June 1, 2001

Accepted: November13, 2001

Beyond the Manual: The Insider's Guide to Prolonged

Exposure Therapy for PTSD
E l i z a b e t h A. H e m b r e e ,

S h e i l a A. M. R a u c h , a n d E d n a B. F o a , University o f P e n n s y l v a n i a

Prolonged Exposure therapy (PE; Foa & Rothbaum, 1998) has strong empirical support for its efficacy in reducing trauma-related
psychopathology in individuals with chronic PTSD (Rothbaum, Meadows, Resick, & Foy, 2000). In the process of providing PE to
man~, clients and in training therapists in a variety of settings in its use, we at the Center for the Treatment and Study of Anxiety
have amassed extensive experience with this therapy. This article extends the treatment guidelines provided in the PE treatment manual by sharing the knowledge and wisdom that years of experience have brought us. We emphasize the importance offo~ging a strong
therapeutic alliance and providing a thorough rationale for treatment, discuss wa~s to implement in-vivo and imaginal exposure so
as to promote effective emotional engagement with traumatic memories, and conclude with some recommendations for how therapists
who conduct PE for PTSD can take care of themselves while delivering a therapy that is very ren,arding and, at times, emotionally
challe,ging.

EVERAL c o g n i t i v e - b e h a v i o r a l t h e r a p i e s (CBT) have

d e m o n s t r a t e d efficacy for the t r e a t m e n t o f P T S D - - f o r
e x a m p l e , P r o l o n g e d E x p o s u r e (PE), Cognitive Processing
T h e r a p y (CPT), a n d Stress I n o c u l a t i o n T r a i n i n g (SIT; for
reviews see F o a & R o t h b a u m , 1998; R o t h b a u m , Meadows,
Resick, & Foy, 2000). PE, w h i c h involves r e p e a t e d imaginal e x p o s u r e to the t r a u m a t i c m e m o r y ( t r a u m a reliving)
a n d r e p e a t e d in-vivO e x p o s u r e to safe situations that are
a v o i d e d , has b e e n o n e o f the m o s t investigated treat-

Cognitive

and

Behavioral

Practice

10, 22-30,

2003

1077-7229/03/22-3051.00/0
Copyright 2003 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.

m e n t s for PTSD. Its efficacy has b e e n d e m o n s t r a t e d with

a wide r a n g e o f p o p u l a t i o n s , i n c l u d i n g f e m a l e sexual assault survivors (Foa, R o t h b a u m , Riggs, & M u r d o c k , 1991;
Foa et al., 1999), m a l e c o m b a t v e t e r a n s (e.g., K e a n e , Fairbank, Caddell, & Z i m e r l i n g , 1989), a n d m i x e d g e n d e r
samples e x p o s e d to a variety o f t r a u m a t i c e x p e r i e n c e s
(Devilly & S p e n c e , 1999).
S o m e studies suggest that PE m a y e i t h e r be m o r e efficacious o r m o r e efficient t h a n alternative t r e a t m e n t s f o r
PTSD. Foa et al. (1999) c o m p a r e d PE to SIT (anxietymanagement training focused on posttrauma reactions)
a n d t h e i r c o m b i n a t i o n ( P E / S I T ) . T h e SIT t r e a t m e n t
u s e d in this study was a d a p t e d f r o m V e r o n e n a n d Kilpatrick's (1983) SIT p r o g r a m . It i n c l u d e d t r a i n i n g in