In-vivo, imaginal and interoceptive exposure

Domain II · Behavioural & cognitive · Craske, Foa, Öst

What it is

This is not one therapy but a family of procedures that form the core of most CBT packages for anxiety, OCD and PTSD. Three channels are used: in vivo (real feared situations, objects, activities), imaginal (feared memories, images or outcomes held in mind, spoken, written or recorded), and…

Format

• Exposure is delivered in a recognisable arc whatever the channel. Session counts below come from specific protocols; for exposure embedded in other CBT packages, follow that package's schedule.
• Phase A: Assessment and formulation (usually 1–2 sessions). Goals: identify feared cues (external, internal, mental), feared outcomes, avoidance, escape and safety behaviours (overt and subtle), and medical or risk issues that change the plan. For panic, a standardised symptom-induction assessment…

Who practises it, and how they are trained or regulated

• PTSD (Prolonged Exposure): about 8–15 sessions, usually weekly or twice weekly. In the protocol outline: session 1 rationale, trauma interview and breathing; session 2 common reactions, in vivo hierarchy; session 3 first imaginal exposure; middle sessions imaginal plus processing plus in vivo review, with hot-spot work introduced around sessions 6–7 in the 2007 guide's training outline (session 4 onward in the older…

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Is there physical contact? Was it explained beforehand, and do you feel free to say no or stop at any point?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Does it involve fasting, a special diet or 'detox'? Have you discussed this with your doctor?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• Client rushing past the hot spot; slow them down.
• Therapist voice becoming the safety behaviour; fade it.
• Combined trial too difficult — shorten rather than abandon.
• Processing turning into debate; keep it Socratic and brief.
• Plans that rely on avoidance ("I'll just avoid lifts if it comes back").

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.