1) Recent advances in exposure therapy involve deriving customized information about feared cues, events, consequences, and coping mechanisms. 2) Exposure therapy follows the principles of graduated, repeated, and prolonged exposure to feared stimuli to develop non-threat expectancies and reduce fear through inhibitory learning. 3) Maximizing exposure therapy involves combining multiple contextual cues, varying contexts and order of exposure, using reminder cues, and emphasizing credibility, expectancy, therapeutic alliance, and goal setting to enhance treatment effects.

1. Recent
advances in
exposure
therapy-
Clinical
application
Narendra Nath Samantaray, Ph.D.
MZU

2. Deriving customized information about
these areas ….
Feared Cues/Events
Feared Consequences/negative
interpretations
Coping mechanisms used by the client

3. Initial step: Conceptualization
Credibility Expectancy Adherence
Understanding
and
communicating
of scientific
rationale

4. Corner = Itching
(pairing or misinterpretation)
Stick
Help from
siblings
Avoidance
Exposure Safety
Behavior

5. Clinical Translation
Feared
events/process
Feared
consequences
Safety
behavior

6. SUD
9.00
(90%)
9.05
(95%)
9.10
(95%)
9.15
(70%)
9.20
(55%)
9.25 (45
%)
Popular principles
Graduated
Repeated
Prolonged

7. Threat
expectancy
CS = US
(Unwashed dress=
Disease)
Non threat
expectancy
CS = no US
(Unwashed dress =
No Disease)
Cue
(Unwashed
dress)
10/11/2022
Inhibitory learning concepts
(Craske et al., 2014)

8. Threat
expectancy
CS = US
(Unwashed dress=
Disease)
Non threat
expectancy
CS = no US
(Unwashed dress =
No disease)
Cue
(Unwashed
dress)
10/11/2022
Inhibitory learning concepts
(Craske et al., 2014)

9. PRE-EXPOSURE POST-EXPOSURE
EXPOSURE
Threat
Expectancy
(If I panic I m
going to die)
Non Threat
Expectancy
(If I panic I’m
n’t going to
die)
?
Fear
No/less
Fear
10/11/2022
Context specific, Time,
Reinstatement of fear
@(40) Michelle Craske: Exposure Strategies - State of the Art - YouTube

10. Expectancy violation
Learning is better consolidated, and this enhances
storage strength too. A format can be used.
Temporal prediction (What length of time, if u are
going to hold knives, do you expect to harm others? )
Intensity of expected US (How intense will be the
disease)
Frequency or occurrence (What's the likelihood of
disease every time you are exposed to public toilets?, SAD)
Capacity to tolerate

11. Deepened Extinction
10/11/2022
Combination of multiple CS cues
All combined cues predict the same US
Can be internal + external; internal+ internal
cues; external + external
Increases mismatch of expectancy, reduces
reinstatement of fear & spontaneous recovery

12. Variability in context
10/11/2022
Benefits: Pairing of retrieval cues & believed
to enhance the storage capacity
Beyond clinic and home; exposure of toilets in
restaurants, and etc
Imaginal blasphemous images at different
places
Use of surprise cards (prepares for
reinstatement of fear)

13. Variability in the order of cues
• Random Order.
• May start with least to
avoid treatment refusal
• Situations do not
naturally occur in
hierarchical manner in
the real world! - EV
• Naturally, emotional state
(i.e., variable level of fear)
serves as a retrieval cue
• May fail to habituate but
beneficial in long-terms
• Our experience
Image from @ Random Picker- Randomly pick an item from a list
(gigacalculator.com)

14. Reminder Cues
• Carrying cues (e.g.,
chudi, wrist-band, note-
card as self-instruction)
as memento
• NOT TO BE USED IN the
early part, these
strategies are best
employed as a relapse
prevention skill
Image @ Letter Bracelet Initial Bracelet Initial
Charm Bracelet - Etsy India

15. Maximizing non-specific factor
Credibility,
Expectancy &
Therapeutic-
alliance (TA)
{Have state-like
properties}
TA
a)Bond,
b)agreement
about goals
& c) tasks in
therapy
a) Specifying
goals,
b) goal
monitoring &
c) feedback
about goal
progress
Early treatment success is (arguably)
the most significant predictor of TA

16. Maximizing non-specific factor
Credibility,
Expectancy &
Therapeutic-
alliance (TA)
{Have state-like
properties}
TA
a)Bond,
b)agreement
about goals
& c) tasks in
therapy
a) Specifying
goals,
b) goal
monitoring &
c) feedback
about goal
progress
Early treatment success is (arguably)
the most significant predictor of TA

17. Maximizing non-specific factor
Goals to specific, measurable, attainable & FUNCTIONAL
Examples: Traveling alone to distant places; going alone to
crowded places; increasing time spent in cardio-exercises
Use of self-monitoring checklist: For instance, items are "I am making
efforts in traveling alone to distant places,"; "I am making efforts in
going to crowded marketplaces alone,"; "I am making efforts in
increasing time spent in cardio-exercises," etc. One may select from;'
not at all; slightly; a little bit; moderately; very much; and extremely.
Provide genuine feedback at every session – Multisource feedback.

18. Image @ https://www.pinterest.com/pin/317503842474843834/

19. Suggested readings
• Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T.,
& Vervliet, B. (2014). Maximizing exposure therapy: An
inhibitory learning approach. Behaviour research and
therapy, 58, 10-23.
• Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski,
J., Chowdhury, N., & Baker, A. (2008). Optimizing
inhibitory learning during exposure therapy. Behaviour
research and therapy, 46(1), 5-27.
• Wampold, B. E. (2015). How important are the common
factors in psychotherapy? An update. World
Psychiatry, 14(3), 270-277.