Worry exposure

1. Introduction

Version followed: the worry exposure module of Mastery of Your Anxiety and Worry (MAW), 2nd edition (Zinbarg, Craske & Barlow 2006, therapist guide; Craske & Barlow 2006, client workbook), which goes back to the 1st edition (Craske, Barlow & O'Leary 1992) and to Brown, O'Leary & Barlow's chapter in Barlow's Clinical Handbook of Psychological Disorders. Two variants are given where they differ: Dugas-lineage written/cognitive exposure (Robichaud, Koerner & Dugas 2019, 2nd ed.; Fracalanza, Koerner & Antony 2014), and standardised VR catastrophe scenarios (Guitard, Bouchard, Bélanger & Berthiaume 2019, a key source). [uncertain] The MAW steps below draw on the chapter structure plus published descriptions of the procedure. Specific numbers (25–30 min, 0–8 scale) are marked where they appear.

Worry exposure (also called imaginal or cognitive exposure for GAD) is a CBT technique for generalised anxiety disorder. The client deliberately pictures, as a vivid image, the worst outcome behind a chronic worry and stays with it, instead of thinking about it in words. The rationale comes from Borkovec's cognitive-avoidance theory. Worry is mostly verbal and abstract, and it acts as avoidance: it keeps distressing images and bodily fear responses down, so the feared image is never fully processed. Worry is then negatively reinforced, because the feared outcome usually does not happen and the worry gets the credit. Holding the full image without neutralising lets fear be activated and processed. Older accounts call this emotional processing or habituation. Inhibitory-learning accounts call it learning that the image and the uncertainty can be tolerated. In the Dugas model the core target is intolerance of uncertainty: Guitard et al. state that "uncertainty is the core fear underlying GAD". [source: Guitard et al. 2019; NJ-ACT summary of Borkovec; Psychology Tools summary of MAW TG] Attribution note: Borkovec is sometimes named as founder. Borkovec supplied the theory. The worry exposure procedure as a named module comes from the Barlow/Craske group (Albany, later Boston CARD). [source: MAW TG contents; GATE protocol]

2. Framework

This is a technique/module within CBT for GAD, not a stand-alone therapy, though it has been tested as the main component (Hoyer et al. 2009, worry exposure vs applied relaxation [uncertain: paper not drawn on beyond title and journal]). Format: individual (also group in CARD protocols), weekly, 50–60 min sessions. Exposure sessions may need 60–90 min, so that 25–30 min of sustained imagery plus debrief fits [synthesis].

Position in MAW 2nd ed. (10–12 sessions; group version 12 × 2 h): education about anxiety and GAD (TG chs 4–7) → relaxation (ch 8) → cognitive restructuring of overestimation and catastrophising (chs 9–10) → worry exposure, "Getting to the Heart of Worrying: Facing Your Fears" (ch 11) → worry-behaviour prevention and in-vivo exposure, "From Fears to Behaviors" (ch 12) → problem solving and time management for real problems (ch 13) → maintenance (ch 15). In the CARD group version, session 9 is titled "From worry exposure to worry prevention", with about 20 min of daily home practice logged. [source: Psychology Tools MAW TG listing; GATE protocol NCT01912287]

Phases of the worry exposure module itself:

Dugas CBT-IU version: about 12–16 weekly sessions. Order: psychoeducation and worry awareness → uncertainty recognition and behavioural exposure → re-evaluating the usefulness of worry → problem-solving training (for worries about current problems) → written exposure (for worries about hypothetical situations) → relapse prevention. [source: Dunkley & Robichaud 2022 chapter summary; Robichaud et al. 2019 TOC] [uncertain: exact session numbers not verified]

VR version: standardised scenarios chosen to match the client's main worry theme (hospital, home, student room). Guitard et al. used a single exposure session as an experiment. A pilot (Labbé et al., cited there) used 3 VR exposures. No clinical session schedule has been established. [source: Guitard et al. 2019]

3. Guiding principles

• Worry is avoidance; the image is the target. In practice, if the client is talking about the worry in sentences, exposure has not started yet. Steer them back to a present-tense, sensory picture. [source: Borkovec via NJ-ACT; Schonbach/Skodzik summary]
• Expose to hypothetical worries, solve real problems. In practice, sort each worry first. Worries about current, solvable problems go to problem solving (MAW ch 13; Dugas). Remote or hypothetical worries go to exposure. [source: Dunkley & Robichaud 2022 summary; MAW TG contents]
• Target the core fear, not the surface topic. In practice, follow the worry down ("and if that happened, what then?") until you reach the final picture: abandonment, death, destitution, being blamed. Expose to that. [source: Guitard et al. 2019, scenario based on "worst fear"; Dugas core-fear framing]
• Vivid, specific, first-person, present tense. In practice, coach for sights, sounds, bodily sensations and emotions. In written variants, present tense and naming negative emotions were linked to better outcome. [source: Fracalanza et al. 2014]
• Stay with the same scenario. In practice, repeat the same worst-case scene across trials and do not switch to new variations early. Repeating one scenario outperformed writing variations. [source: Fracalanza et al. 2014]
• No neutralising during exposure. In practice, ask the client to drop reassurance, "it'll be fine" self-talk, rapid scene changes, and imagining a rescue while the image is held. Check for these afterwards. [source: Guitard et al. 2019 on avoidance and neutralisation; Koerner & Fracalanza 2012 on anxiety-control strategies (abstract only)]
• Graded but committed. In practice, start with a moderately distressing image the client can hold. Move up when the current one is manageable. Do not stop a trial at peak distress unless there is a safety concern. [source: MAW hierarchy structure; synthesis]
• Daily repetition matters more than session heroics. In practice, set daily home exposure (MAW CARD protocol: about 20 min daily, logged). [source: GATE protocol]
• Measure every trial. In practice, take anxiety and vividness ratings at start, peak and end, plus a brief prediction and outcome. These guide when to move on. [source: MAW (ratings), uncertain on exact scale; synthesis for prediction ratings]
• Collaborative, transparent stance. In practice, explain why you are asking the client to do something that feels counter-intuitive, get explicit consent, and let them set pace within the hierarchy. [synthesis consistent with GATE consent language: participants may decline uncomfortable procedures]
• Expect a temporary rise in anxiety and worry. In practice, forewarn the client that an initial increase in anxiety is expected and is linked to later improvement in the same-scenario condition. [source: Fracalanza et al. 2014; Atlas known risks]

4. Intervention inventory

Sources for this section: MAW TG chapter structure and Psychology Tools summary (modules, imaginal plus in-vivo exposure); Guitard et al. 2019 (scenario writing, VR); Fracalanza et al. 2014 and Goldman et al. 2007 (written exposure); McIntosh & Crino 2013 (direct imagining vs audio playback); GATE protocol (CARD group format, homework); Skodzik et al. via Schonbach 2018 (imagery training). All example language is illustrative and written for this guide. No manual wording is reproduced.

Safety and consent before any exposure (applies to 4.5–4.11). Screen and defer or adapt for: current suicidal intent or recent self-harm (complete a standard risk assessment first; if the core fear involves death or suicide, run exposure only once risk is assessed as low and a safety plan is in place); psychosis or severe dissociation; current substance misuse that would block processing; a worry that is actually a current real threat (e.g. ongoing domestic violence, unpaid eviction notice), which needs problem solving or safeguarding, not exposure; another primary anxiety disorder that should be treated first. For VR, Guitard et al. excluded claustrophobia (CAVE system), vestibular/inner-ear disease, cardiovascular or circulatory disorders, migraine, blood-pressure disorders, diabetes, and benzodiazepine use; they screened stereoscopic vision and measured simulator sickness before and after. Obtain explicit informed consent covering: rationale, expected rise in anxiety, the right to stop, and how a trial ends. Agree a stop signal. [source: Guitard et al. 2019 (VR exclusions, debrief); GATE protocol (right to decline, AE logging); synthesis for the clinical screening list]

4.1 Rationale: worry as avoidance

• Purpose / when: First step of the module. It turns a counter-intuitive request ("think about the worst") into a sensible experiment and lays the ground for consent and adherence.
• Steps: (1) Ask the client what they notice when they worry: is it words, or pictures? (2) Explain that worry is mostly verbal "what-if" chains that skim from topic to topic and seldom settle on the final picture. (3) Link this to short-term relief and long-term maintenance: worry dampens the full fear response, so the fear is never processed, and when nothing bad happens, the worry seems to have "worked". (4) Introduce the alternative: deliberately hold the worst image long enough for the fear to rise and then change. (5) Check understanding with a teach-back. [source: Borkovec cognitive-avoidance theory via NJ-ACT and Schonbach 2018; MAW TG chs 7 and 11 titles]
• Example language (illustrative): "When you worry, your mind keeps jumping to the next 'what if' and never lands on the scene that really frightens you. We're going to do the opposite: land on it on purpose and stay there, so your brain gets a chance to learn something new about it."
• Watch for: Agreement without belief ("makes sense, but…"). Fear that thinking it will make it happen (thought–action fusion). Address that directly before exposure, e.g. with a brief behavioural experiment [synthesis]. Working: the client can explain the rationale in their own words and names an image they have avoided.

4.2 Worry self-monitoring and sorting worries

• Purpose / when: Phases A and throughout. Identifies the 2–3 main worry spheres and sorts each worry into current problem (to problem solving) or hypothetical/remote (to exposure).
• Steps: (1) Give a simple daily log: time, trigger, worry topic, anxiety rating, what the client did (reassurance, checking, distraction). (2) Review in session and group entries into spheres (e.g. family safety, health, work, finances). (3) For each, ask: is this about something happening now that I can act on? (4) Route current problems to problem solving (MAW ch 13; Dugas problem-solving module). Route hypothetical ones to exposure. [source: MAW TG contents; Dunkley & Robichaud 2022 summary; NJ-ACT on Borkovec's worry outcome diary]
• Example language (illustrative): "Let's sort these. 'The rent is due Friday and I'm short' is a problem we can work on. 'What if my daughter is in a car crash on her trip next year' isn't something we can solve; that's one for exposure."
• Watch for: Logs that list topics only and no images. Missing entries (the worry is so constant the client can't separate episodes; use sampling at set times instead [synthesis]). Working: clear spheres, plus the client starts noticing worry earlier.

4.3 Finding the feared image (downward questioning)

• Purpose / when: Phase A. Moves from the surface worry to the concrete worst-case image that the worry avoids.
• Steps: (1) Take one sphere. (2) Ask repeatedly what the client fears would happen next, and what would be worst about that, until the answer is a concrete scene rather than an abstract statement. (3) Get the specifics: where, who is there, what is said, what the client sees, hears and feels in their body. (4) Write a one-line summary of the image for the hierarchy. (5) Repeat for each sphere. [source: Guitard et al. 2019 (scenario based on the main worry theme and worst fear); Dugas core-fear framing; MAW "heart of worrying" chapter title. The questioning sequence is synthesis]
• Example language (illustrative): "Suppose your worst fear about this came true. Take me to the moment it's worst. Where are you? Who's there? What's happening right in front of you?"
• Watch for: Stopping at an abstract level ("I'd be a failure"). Keep going until there is a scene. Strong emotion during questioning signals you are near the core. Working: the client gets visibly anxious and says something like "that's the one I never let myself think about".

4.4 Imagery training

• Purpose / when: Phase B, before the first exposure, especially for clients who say "I don't see pictures". GAD worry is mostly verbal, and some clients struggle to imagine. [source: Guitard et al. 2019; Skodzik et al. via Schonbach 2018; MAW includes imagery practice (uncertain: details not verified)]
• Steps: (1) Explain the difference between thinking about something in words and picturing it. (2) Practise with a neutral scene (e.g. their kitchen), then a pleasant one. Eyes closed, describe aloud in present tense, and prompt each sense. (3) Rate vividness (e.g. 0–10) and difficulty. (4) Give feedback to add detail. (5) Home practice: a few minutes daily with everyday scenes. In the Skodzik study, a single training session covered: noticing imagery in daily life, telling verbal from image-based thinking, generating images to audio prompts, and practising 10 brief worry scenes described aloud with feedback on sensory detail, then daily practice for a week. [source: Schonbach 2018 summary of Skodzik et al.]
• Example language (illustrative): "Close your eyes and stand in your kitchen. Tell me, as if it's happening now, what you see on the counter… What can you hear? What does the floor feel like under your feet?"
• Watch for: Narrating in past tense or third person, or describing rather than seeing. Coach toward "I am…". Working: vividness ratings rise, and the client can hold a scene for several minutes.

4.5 Building the worry-exposure hierarchy

• Purpose / when: Phase C. Orders the feared images so exposure is graded.
• Steps: (1) List the worst-case image from each sphere, plus milder variants if the worst is too much to start with. (2) Have the client rate the expected anxiety for each (0–100 or 0–8) [uncertain: MAW uses a 0–8 scale in its forms as recalled; unverified]. (3) Order from lowest to highest. (4) Pick a starting item that is clearly distressing but that the client agrees to hold. [source: MAW (hierarchy is part of the procedure, per secondary descriptions); scale and start-point are synthesis]
• Example language (illustrative): "Of these four pictures, which would you be willing to stay with for half an hour today, knowing it'll be uncomfortable? We'll work up to the hardest one."
• Watch for: Hierarchies padded with low items as avoidance. Items that are real current problems (move them to problem solving). Working: the client can rank items quickly and commits to a start item.

4.6 In-session imaginal worry exposure (MAW core procedure)

• Purpose / when: Phase D. The central technique: sustained, vivid imagery of the worst-case outcome without neutralising.
• Steps: (1) Review consent and the stop signal. Take a baseline anxiety rating. (2) Optionally do a brief predictions check: "What do you expect will happen if you hold this image for 25 minutes?" [synthesis, inhibitory-learning]. (3) Client closes their eyes and describes the hierarchy image aloud in first person, present tense. The therapist prompts sensory and emotional detail and steers the client back if they drift to verbal worry or skip ahead. (4) Ask the client to hold the image at full intensity for about 25–30 minutes [uncertain: duration as commonly attributed to MAW and Brown, O'Leary & Barlow]. (5) Take anxiety and vividness ratings at intervals (e.g. every 5 min) and note the peak. (6) End the trial, open eyes, take final ratings. (7) Debrief: what happened to the anxiety, what the client learned, whether they neutralised (see 4.11), and what surprised them versus their prediction. (8) Record on an exposure log and set the same image for daily home practice. [source: MAW (imaginal exposure to feared outcomes, per Psychology Tools TG summary); Guitard et al. 2019 (seated imaginal exposure to personalised scenario); McIntosh & Crino 2013 (direct imagining outperformed audio playback in a 9-person pilot)]
• Example language (illustrative): "Stay right there. You're standing in the hospital corridor; the doctor is walking toward you. What's his face doing? What do you feel in your chest? Don't jump ahead and don't fix it. Just be there."
• Watch for: Anxiety that stays flat and low (the image is not vivid, or the client is avoiding; see 4.11 and section 5). Rapid scene-switching. Rescue fantasies. Working: anxiety rises at the start, then over repeated trials peak and end ratings fall, or the client reports it is "bearable" and the image loses its grip. Day-to-day worry about that sphere declines.

4.7 Generating alternative outcomes after exposure

• Purpose / when: In the 1st-edition and handbook versions of the Barlow/Craske protocol, after the exposure period the client generated as many alternative, less catastrophic outcomes as possible, to loosen the fixed catastrophic prediction. [uncertain: described in secondary literature on the original protocol; whether this step is kept in MAW 2nd ed. was not verified]
• Steps: (1) Only after the full exposure period, never during it (doing it during exposure would work as neutralising) [synthesis]. (2) Ask for a list of other ways the situation could turn out, including neutral and mixed outcomes. (3) Do not argue probability here. That belongs to the cognitive module on overestimation and catastrophising (MAW chs 9–10). [source: MAW TG contents]
• Example language (illustrative): "You've stayed with the worst version. Now, just as an exercise, how many other endings can you list, without deciding which is true?"
• Watch for: The client using alternatives as reassurance before the next trial. If this happens, drop the step, especially under a Dugas/uncertainty framing, where the aim is tolerating not knowing [synthesis]. Working: the list comes easily and the client holds it lightly.

4.8 Written exposure / cognitive exposure (Dugas lineage)

• Purpose / when: Alternative or adjunct to 4.6 for hypothetical worries, for clients who find spoken imagery hard, or when the therapist cannot tell whether the client is truly imagining. It also suits home practice and internet delivery.
• Steps: (1) Identify the core fear (4.3). (2) In session, the client starts writing a scenario of the feared outcome in first person, present tense, with sensory and emotional detail. Starting in session lets the therapist review content and give feedback (Guitard et al.). (3) The client finishes and refines it at home. (4) Exposure: the client writes about the same worst-case scenario repeatedly. Fracalanza et al. used about 20 min per session on 3 consecutive days. Same-scenario writing reduced worry, cognitive avoidance and intolerance of uncertainty, and writing about variations did not. (5) Encourage present tense and explicit naming of emotions. Both were associated with better outcome. [source: Fracalanza, Koerner & Antony 2014; Guitard et al. 2019; Robichaud et al. 2019 describe written exposure for lingering worries and core fears; Goldman et al. 2007]
• Example language (illustrative): "Write it as if it's happening right now, in 'I' form. Put in what you see, hear, and feel, and name the emotions. Write for twenty minutes without stopping to reassure yourself."
• Watch for: Stories that end with a rescue or a happy resolution. Detached reporting style. Rewriting a new scenario each time. Working: anxiety at the start of writing that falls across sessions; less urge to avoid the topic.

4.9 Audio-recorded scenario and repeated listening

• Purpose / when: A variant where the client records the scenario (reading their script, or the therapist's guided narration) and listens repeatedly, mainly for home practice. [source: McIntosh & Crino 2013 (audio record-and-playback arm); earlier Dugas protocols used recorded scenarios (uncertain: 2007 manual)]
• Steps: (1) Record the scenario in first person, present tense. (2) Listen daily with full attention, no multitasking, for a set period. (3) Rate anxiety before, at peak and after.
• Example language (illustrative): "Sit somewhere you won't be interrupted, play the recording, and let yourself be in the scene rather than just hearing the words."
• Watch for: Passive listening and habituation to the voice rather than the image. In the McIntosh & Crino pilot, only half of the audio-playback participants reached subclinical GAD, compared with all of the direct-imagining participants. Prefer direct imagining where feasible, and use audio as support. [source: McIntosh & Crino 2013] Working: the same signs as 4.6.

4.10 Virtual-reality catastrophe scenario exposure

• Purpose / when: An option when personalised imagery is weak or impossible to monitor, or for clinics with VR. The content is visible to the therapist, which reduces hidden avoidance. [source: Guitard et al. 2019]
• Steps (as in the study, not a validated clinical protocol): (1) Screen for VR exclusions (see safety box) and take a simulator-sickness baseline. (2) Neutral familiarisation: about 5 min in a quiet, empty virtual room, walking around. (3) The clinician chooses the standardised scenario that best matches the client's main worry theme. Guitard et al. used an emergency waiting room (illness and ambiguous doctors' talk), an apartment (overheard accident hints, burglary alert, fight outside, plus one of seven voicemails such as police call, test results, breakup or debts), or a student room (exams, bills, social exclusion). (4) Immersion with anxiety ratings before and after. (5) Re-check simulator sickness and debrief. (6) In a pilot cited by Guitard et al., the emergency-room scenario alone was given 3 times, with reported gains at 2-month follow-up. [source: Guitard et al. 2019] [uncertain: no established session count; the scenarios are standardised, not personalised]
• Example language (illustrative): "In this room you'll hear and see things that might connect to your worries. Let yourself notice them and stay in the room rather than tuning out. Tell me your anxiety from 0 to 100 when I ask."
• Watch for: Simulator sickness (headache, nausea, dizziness) mistaken for anxiety. Low presence. In the study, a stronger sense of presence predicted more anxiety, so low presence means a weak exposure. Theme mismatch. Working: anxiety elicited comparable to personalised imagery (as found), then a decline over repeated sessions [synthesis].

4.11 Detecting and blocking neutralising during exposure

• Purpose / when: Every exposure trial. Covert anxiety-control strategies (reassuring self-talk, distraction, switching scenes, imagining rescue, praying, or "undoing" the image) can weaken imaginal exposure. Therapists "cannot easily tell" what clients are imagining, so they must ask. [source: Guitard et al. 2019; Koerner & Fracalanza 2012 (chapter reviews whether anxiety-control strategies help or hinder imaginal exposure; abstract only, evidence described as unresolved)]
• Steps: (1) Before exposure, list the client's usual mental escapes. (2) Agree to notice and drop them, returning to the image. (3) After the trial, ask specifically which ones showed up. (4) Plan to drop them on the next trial and in home practice.
• Example language (illustrative): "Did any part of your mind step in to make it okay, like telling yourself it won't happen, or picturing someone arriving to help? No problem if it did; let's catch it next time."
• Watch for: Low anxiety with high reported vividness, which often means neutralising. Working: honest reporting of neutralisers, with fewer of them over trials. [uncertain: Koerner & Fracalanza note the evidence on whether any coping during imaginal exposure is harmful is mixed. A brief grounding skill used after a trial is not neutralising (synthesis)]

4.12 Daily home worry exposure and logging

• Purpose / when: From the first in-session trial onward. Consolidates learning and generalises it.
• Steps: (1) Same image or script as in session. (2) A fixed daily slot. The CARD group protocol prescribes about 20 min of daily practice recorded in a homework log, with adherence rated. (3) Log date, image, duration, start, peak and end anxiety, vividness, neutralisers and a one-line learning point. (4) Review the log at the start of every session. [source: GATE protocol NCT01912287]
• Example language (illustrative): "Same picture, same time each day, 20 to 30 minutes, then fill in the four numbers and one sentence about what you noticed."
• Watch for: Practice dropping off as anxiety falls, or practice timed for when the client feels "strong" (a safety behaviour). Working: falling peak ratings across the week and spontaneous drop in worry time.

4.13 Worry-behaviour prevention and in-vivo exposure (MAW companion module)

• Purpose / when: After or alongside imaginal exposure (MAW ch 12, "From Fears to Behaviors"; CARD session "From worry exposure to worry prevention"). Targets overt worry behaviours that keep worry going: reassurance seeking, checking, over-preparing, avoiding news or situations, and procrastination. [source: MAW TG contents; GATE protocol; Psychology Tools TG summary (imaginal and in-vivo exposure)]
• Steps: (1) Identify worry behaviours from logs. (2) Rank them. (3) Agree to reduce or stop them stepwise (e.g. call partner once rather than five times; read the news; leave email unchecked for set periods), or to enter avoided situations. (4) Rate predicted versus actual anxiety and outcome. [steps are synthesis consistent with MAW's described module]
• Example language (illustrative): "This week, let's see what happens if you text your son once at the agreed time instead of every hour. What do you predict, and how will we know?"
• Watch for: Swapping one safety behaviour for another. Family members continuing to give reassurance (involve them if appropriate). Working: fewer worry behaviours, and the client notices that outcomes did not depend on them.

4.14 Optimising exposure with inhibitory-learning strategies [synthesis]

• Purpose / when: To strengthen phases D–E. Guitard et al. cite Craske et al.'s inhibitory-learning model of exposure. The specific applications below are this guide's synthesis and are not part of the MAW worry-exposure protocol as verified.
• Steps: (1) Expectancy violation: before each trial, the client states a specific feared prediction about the exposure itself (e.g. "I'll lose control", "the anxiety will never stop", "I'll be unable to function today"). Compare with what happened afterwards. (2) Variability: once the core image is manageable, vary context (time of day, place, written vs spoken). Keep the scenario constant within early trials, given Fracalanza et al. (3) Affect labelling: name emotions during the image. (4) Remove safety signals: practise without the therapist present or without comforting objects.
• Example language (illustrative): "Before we start: on a scale of 0 to 100, how sure are you that if you hold this for 25 minutes you'll still be wrecked this evening? We'll check tonight."
• Watch for: Technique overload. Keep the core sustained image central. Working: predictions about the dangers of anxiety and uncertainty drop.

5. Handling problems

The sources say little about troubleshooting. Guitard et al. flag difficulty imagining and hidden avoidance or neutralisation, Fracalanza et al. flag the initial anxiety rise, and the GATE protocol covers distress, the right to decline and AE logging. Everything else here is marked [synthesis].

• Can't form images / "I just think in words". Go back to imagery training (4.4) with neutral scenes. Switch to written exposure (4.8), which does not need visual imagery. Consider VR (4.10) where available. [source: Guitard et al. 2019; Schonbach/Skodzik]
• Low or flat anxiety during exposure. Check that you have the core image, not a surface one (redo 4.3). Check for neutralising (4.11). Check that the image is present tense and first person. Increase sensory and emotional detail. Move up the hierarchy. [synthesis; Fracalanza et al. 2014 on present tense and emotion words]
• Overwhelm (panic, crying, dissociation). Keep the client in the room. Lower intensity rather than ending at peak (e.g. step back to a less extreme version of the scene, open eyes but keep talking about it). Then return. If the client is dissociating (glazed, disconnected, time loss), stop exposure, ground them in the present, and reconsider readiness. Screen for trauma, because worst-case images can tap trauma memories that need a PTSD protocol. Debrief and make sure the client is settled before leaving. [synthesis; Guitard et al. 2019 debrief and referral practice]
• Brief rise in worry and anxiety between sessions. Forewarn the client in advance (Atlas lists this as a known risk). Normalise it as expected: an early anxiety increase was associated with better outcomes in same-scenario writing. Keep home practice going rather than pausing. Review at the next session. [source: Fracalanza et al. 2014; GATE AE monitoring]
• Non-adherence to home practice. Find out why: fear, misunderstanding the rationale, or logistics. Re-link to the rationale (4.1). Shorten and schedule the practice. Do the first home trial in session. Use the log review as the first agenda item every session. In the CARD trial, adherence counted as ≥4 on a 0–6 compliance scale plus attending 10 of 12 sessions, which shows the protocol expects most practice to be done. [source: GATE protocol; remaining points synthesis]
• "Thinking it will make it happen" / magical thinking. Address it before exposure: explore the belief, run a small behavioural experiment (e.g. vividly imagining a neutral improbable event), and frame exposure as an experiment. [synthesis]
• The worry is actually realistic. If the scenario is a current, likely problem, pause exposure and use problem solving (MAW ch 13; Dugas problem-solving module). Exposure is for hypothetical worries. [source: MAW TG contents; Dunkley & Robichaud 2022 summary]
• Content involves suicide, self-harm or harm to others. Do a standard risk assessment before using such content. If there is current ideation, prioritise safety planning and lethal-means counselling (safe storage and removal) over exposure. Never script method detail into scenarios. Intrusive harm images with neutralising may indicate OCD rather than GAD: reassess. [synthesis; standard practice]
• Rescripting or reassurance creeping in. Clients rewrite the ending ("and then she's fine"). Name it kindly, explain why the scene should stay unresolved, and rewrite the ending as open or bad. Do not pre-plan alternatives during the trial (see 4.7). [synthesis; Fracalanza et al. on same-scenario repetition] [uncertain: a separate line of research tests written exposure with rescripting (Ovanessian et al. 2018, title only seen); this guide does not cover that procedure]
• Stuck: no change after several trials. Check dose (25–30 min in session, and daily practice). Check whether it is the same scenario each time. Check for subtle neutralising and for overt worry behaviours that undo gains (4.13). Check whether the image is really the core fear. Consider switching mode (spoken ↔ written). Review comorbid depression or alcohol use. [synthesis]
• Resistance and ruptures ("you're making me worse"). Validate, slow down, and repair openly: own any pacing errors, return to the client's goals, and offer choice of item and mode within the hierarchy. Do not abandon exposure entirely without discussing the trade-off. The GATE protocol confirms the client's right to decline any procedure. [source: GATE protocol; remainder synthesis]
• VR-specific problems. Simulator sickness: stop, rest, and resume or reschedule. Theme mismatch: choose the closest scenario or return to personalised imagery. Low presence: expect weaker effect. [source: Guitard et al. 2019 (SSQ monitoring, presence predicting anxiety); management synthesis]
• Worry about worry (metacognitive "I'll go crazy if I let myself think this"). Treat this as the prediction to test in exposure (4.14). The CARD protocol has a separate session on worrying about worry, drawing on Wells. [source: GATE protocol; synthesis for the exposure link]

Sources

Sources:

• Guitard et al. 2019, Exposure to a standardized catastrophic scenario in VR or a personalized scenario in imagination for GAD (J Clin Med, MDPI full text). Same article as the key source PMC6463165. Metadata confirmed via Europe PMC.
• Psychology Tools: Mastery of Your Anxiety and Worry (2nd ed.) Therapist Guide summary and chapter list
• Oxford Academic: MAW Therapist Guide, ch. 3 (abstract)
• Oxford Academic: MAW Therapist Guide, ch. 7 (abstract)
• GATE: Generalized Anxiety, A Treatment Evaluation, protocol NCT01912287 (CARD CBT for GAD, group)
• McIntosh & Crino 2013, Towards a unified worry exposure protocol for GAD: a pilot study (Behaviour Change, abstract)
• Fracalanza, Koerner & Antony 2014, Testing a procedural variant of written imaginal exposure for GAD (abstract)
• Koerner & Fracalanza 2012, The role of anxiety control strategies in imaginal exposure (Springer, abstract)
• Robichaud, Koerner & Dugas 2019, CBT for GAD: From Science to Practice, 2nd ed. (Routledge page and TOC)
• Dunkley & Robichaud 2022, CBT for GAD: Targeting intolerance of uncertainty (Cambridge chapter page)
• Dugas, GAD: differential diagnosis and CBT (MUN newsletter)
• NJ-ACT: Borkovec's approach to GAD
• Schonbach 2018, Imagining your worries away (TMU CAP Lab, on Skodzik et al.)
• Krzikalla et al. 2024, Worry postponement RCT (Europe PMC); used only to rule out

Further reading (not drawn on) [uncertain where relied on]:

• Craske, M. G., Barlow, D. H., & O'Leary, T. (1992). Mastery of Your Anxiety and Worry. Graywind.
• Zinbarg, R. E., Craske, M. G., & Barlow, D. H. (2006). Mastery of Your Anxiety and Worry: Therapist Guide (2nd ed.). Oxford University Press.
• Craske, M. G., & Barlow, D. H. (2006). Mastery of Your Anxiety and Worry: Workbook (2nd ed.). Oxford University Press.
• Brown, T. A., O'Leary, T. A., & Barlow, D. H. Generalized anxiety disorder. In D. H. Barlow (Ed.), Clinical Handbook of Psychological Disorders (2nd ed. 1993; 3rd ed. 2001). Guilford.
• Borkovec, T. D. (1994). The nature, functions, and origins of worry. In G. Davey & F. Tallis (Eds.), Worrying: Perspectives on Theory, Assessment and Treatment. Wiley.
• Hoyer, J., Beesdo, K., Gloster, A. T., Runge, J., Höfler, M., & Becker, E. S. (2009). Worry exposure versus applied relaxation in the treatment of generalized anxiety disorder. Psychotherapy and Psychosomatics, 78, 106–115 (page blocked).
• Dugas, M. J., & Robichaud, M. (2007). Cognitive-Behavioral Treatment for Generalized Anxiety Disorder: From Science to Practice. Routledge.
• Goldman, N., Dugas, M. J., Sexton, K. A., & Gervais, N. J. (2007). The impact of written exposure on worry. Behavior Modification.
• van der Heiden, C., & ten Broeke, E. (2009). The when, why, and how of worry exposure. Cognitive and Behavioral Practice.
• Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy.