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Maximizing exposure therapy: An inhibitory learning approach
Open accessAbstract
Exposure therapy is an effective approach for treating anxiety disorders, although a substantial number of individuals fail to benefit or experience a return of fear after treatment. Research suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. Targeting these processes may help improve the efficacy of exposure-based procedures. Although evidence supports an inhibitory learning model of extinction, there has been little discussion of how to implement this model in clinical practice. The primary aim of this paper is to provide examples to clinicians for how to apply this model to optimize exposure therapy with anxious clients, in ways that distinguish it from a ‘fear habituation’ approach and ‘belief disconfirmation’ approach within standard cognitive-behavior therapy. Exposure optimization strategies include 1) expectancy violation, 2) deepened extinction, 3) occasional reinforced extinction, 4) removal of safety signals, 5) variability, 6) retrieval cues, 7) multiple contexts, and 8) affect labeling. Case studies illustrate methods of applying these techniques with a variety of anxiety disorders, including obsessive-compulsive disorder, posttraumatic stress disorder, social phobia, specific phobia, and panic disorder.
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“According to this rationale, both unlearning old catastrophic interpretations and learning a wide range of new associations form the key to therapeutic change.”
From Personalized exposure and experience sampling method feedback versus exposure as usual for obsessive–compulsive disorder: a study protocol for a randomized controlled trial (2024) · cites this paper as [24]
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In the citing paper
“However, the mechanisms of change in exposure therapy are still not well understood, especially in exposure therapy for EDs”
From Are within- and between-session changes in distress associated with treatment outcomes? Findings from two clinical trials of exposure for eating disorders (2024) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Emotional states are strong retrieval cues, and variation in fear may increase the salience of the association between a previously feared object or situation and a lack of extreme negative consequences (Bjork & Bjork, 1992, 2006; Craske et al., 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Variability in the exposure hierarchy may also enhance expectancy violation, which is proposed to maximize exposure therapy outcomes (Craske et al., 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Instead of starting exposure with the premise of random progression through the exposure hierarchy, variability might be introduced after a few graded exposures of lower difficulty once the client has gained confidence in his or her ability to stay in the distressing situation (Craske et al., 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measured
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In the citing paper
“SUDS are not typically part of the inhibitory learning model, as there is no emphasis on habituation (Craske et al., 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“While the precise mechanisms supporting novelty-facilitated extinction remain unclear, the strategic incorporation of novelty into extinction may leverage effects of surprise that are central to inhibitory learning (1,3).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Exposure is hypothesized to be effective when the new association becomes stronger than the old association.”
From Personalized exposure and experience sampling method feedback versus exposure as usual for obsessive–compulsive disorder: a study protocol for a randomized controlled trial (2024) · cites this paper as [24]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Furthermore, the meta-analyses primarily used data from same-day or next-day uninstructed threat extinction training with only one session, limiting the generalizability of the results to real-world exposure-based therapies (i.e., which typically involve instructions about assessing the likelihood of aversive events and often comprise more than one session) (8).”
From I Doubt It Is Safe: A Meta-analysis of Self-reported Intolerance of Uncertainty and Threat Extinction Training (2021) · cites this paper as [8]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“To this end, it is important to detect patients’ specific expectancies and to record the belief in these expectancies before exposure starts. This technique can help to reduce catastrophic thinking (Craske et al., 2014; Schyns et al., 2016; Schyns, Roefs, et al., 2018; Schyns, van den Akker, Roefs, Hilberath & Jansen, 2018).”
From A new cognitive behavior therapy for adolescents with avoidant/restrictive food intake disorder in a day treatment setting: A clinical case series. (2019) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“One of the main strengths of the current study is that the treatment intervention (behavioral experiments) and treatment target (intolerance of uncertainty) are solidly grounded in the anxiety disorders literature.”
From Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder (2022) · cites this paper as Craske et al., 2014
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“This exposure generates new learning of safety-based associations that inhibit former fear response associations to the feared stimulus [77, 78, 118], thereby either extinguishing the fear response or enabling a level of fear tolerance that reduces anxious distress.”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [78]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“Two factors are generally considered unique to CBT, “exposure” and “coping efficacy”, or skill building [77, 78].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [78]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“These findings add to the growing literature suggesting that, instead, change can occur during exposure therapy without within-session reduction in distress via inhibitory learning processes (Craske et al., 2014; Essayli et al., 2023).”
From Are within- and between-session changes in distress associated with treatment outcomes? Findings from two clinical trials of exposure for eating disorders (2024) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“The inhibitory learning model is applicable to a wide spectrum of anxiety content.”
From Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic (2022) · cites this paper as Craske et al., 2014
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In the citing paper
“The degree to which these exposures more closely replicate the avoided experience (e.g., provoking a strong sensation) and create an expectancy violation (i.e., helping the individual to learn that outcomes differ from expectations), the more effective the interoceptive exposure.”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Craske et al., 2014
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In the citing paper
“One hypothesis whereby interoceptive exposure treatments exert their influence is via inhibitory learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014
The cited source says what the claim attributes to it.
In the citing paper
“According to this model, exposures that intentionally provoke interoceptive sensations should be designed to disconfirm underlying expectancies of negative outcomes (e.g., I can’t handle pain; Craske et al., 2014).”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Context and stimulus variability appear to be key in the generalization of learning, which allows clients to apply what they have learned to new contexts and new stimuli that were not encountered during exposure therapy (Craske et al., 2014; Kircanski et al., 2012).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Increasing variability is one potential modification to the delivery of exposure therapy that could maximize inhibitory learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).”
From Enhancing Inhibitory Learning: The Utility of Variability in Exposure (2019) · cites this paper as Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014
The cited source says what the claim attributes to it.
In the citing paper
“For example, exposure therapy works to lessen negative affect through a mechanism principal to the defensive system – fear extinction (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014).”
From Examining Positive and Negative Affect as Outcomes and Moderators of Cognitive-Behavioral Therapy and Acceptance and Commitment Therapy for Social Anxiety Disorder. (2019) · cites this paper as Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014
The cited source says what the claim attributes to it.
In the citing paper
“Difficulty learning about safety via extinction can arise in anxiety disorders and following trauma, and principles of extinction form the basis of exposure-based therapies (1).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“Difficulty learning about safety via extinction can arise in anxiety disorders and following trauma, and principles of extinction form the basis of exposure-based therapies (1).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“Instead, exposure therapy may be best optimized through strategies that enhance inhibitory learning, such as expectancy violation and variability in exposure (1).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“Importantly, conceptualizations of the mechanisms supporting the effects of exposure therapy have increasingly shifted to emphasize inhibitory learning.”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“While habituation likely plays a role in extinction and while fear often decreases over the course of an exposure, the extent to which fear declines does not predict clinical outcomes (1).”
From When Uncertainty Is a Certainty: Optimizing Exposure-Based Therapies (2021) · cites this paper as [1]
The cited source says what the claim attributes to it.
In the citing paper
“Several studies have shown that learning is context-dependent and that exposure in multiple contexts appears to counteract a return of fear [6, 24].”
The cited source says what the claim attributes to it.
In the citing paper
“A promising intervention that aims at breaking such self-reinforcing circles of anxiety and safety behaviours is exposure therapy [30, 33, 34].”
From Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa (2024) · cites this paper as [30]
The cited source says what the claim attributes to it.
In the citing paper
“Recent research suggests that exposure therapy should be based on inhibitory learning principles, such as expectancy violation [30, 45].”
From Anxiety matters: a pilot lab study into food, weight, and virtual body exposure in anorexia nervosa (2024) · cites this paper as [30]
The cited source says what the claim attributes to it.
In the citing paper
“behavioral experiments, which require clients to formulate specific predictions and to compare their predictions to actual outcomes following an exposure-type situation, are directly in line with contemporary learning theories of fear reduction (e.g., Craske et al., 2014).”
From Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder (2022) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“IU-CBT is also influenced by current approaches to exposure that are based on findings that habituation within and between sessions is not necessary in order to achieve functional improvement (Craske et al., 2008;Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014;Jacoby & Abramowitz, 2016).”
From Intolerance of Uncertainty–Focused Treatment for Adolescents With Excessive Worry: A Pilot Feasibility Study (2020) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“These studies are in line with the work carried out by Craske et al. [81], focused on optimizing exposure therapy based on the inhibitory learning approach, because VR/AR can maximize some strategies reported by Craske.”
From In Vivo versus augmented reality exposure in the treatment of small animal phobia: A randomized controlled trial (2016) · cites this paper as Craske et al. [81]
The cited source says what the claim attributes to it.
In the citing paper
“Consolidation of this “safety” learning is essential for the success of exposure therapy (Craske et al., 2014).”
From Using sleep to enhance exposure treatment for anxious children: A pilot study. (2026) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Within an inhibitory learning framework of understanding (Craske et al., 2014), the new learning of safety will constrain and dampen the old learning that others intend harm.”
From A counterweight model for understanding and treating persecutory delusions. (2025) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Exposure therapy, which involves repeatedly exposing oneself to stimuli that cause fear, is an integral part of cognitive behavioral therapy for anxiety disorders (Craske et al., 2014).”
From Speaking face-to-face with a virtual avatar to reduce anxiety in students who stutter: Tool development and pilot study results. (2026) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Craske, Treanor, Conway, Zbozinek, and Vervliet (2014) suggest that exposure therapy works through inhibitory learning, indicating that expectancy violation (and not fear decrease) should be its main objective.”
From A new cognitive behavior therapy for adolescents with avoidant/restrictive food intake disorder in a day treatment setting: A clinical case series. (2019) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Whereas some presentations of ARFID are clearly anxiety‐driven (e.g., specific phobia of choking/vomiting), and appear to suit Craske's et al. (Craske et al., 2014) theory quite well, not all presentations appear to be primarily characterized by anxiety.”
From A new cognitive behavior therapy for adolescents with avoidant/restrictive food intake disorder in a day treatment setting: A clinical case series. (2019) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Nowadays it is believed that exposure in vivo sets off a process of inhibition in which the association of the conditioned stimulus (CS) (social situations) and the feared unconditioned stimulus (US) (humiliation) is inhibited by the forming of new associations around the CS, of which the association with ‘no-US’ (no rejection) is probably the most important [34].”
The cited source says what the claim attributes to it.
In the citing paper
“behavioral experiments, which require clients to formulate specific predictions and to compare their predictions to actual outcomes following an exposure-type situation, are directly in line with contemporary learning theories of fear reduction (e.g., Craske et al., 2014).”
From Behavioral Experiments for Intolerance of Uncertainty: A Randomized Clinical Trial for Adults With Generalized Anxiety Disorder (2022) · cites this paper as Craske et al., 2014
The cited source says what the claim attributes to it.
In the citing paper
“Tolerance of exposure, with inhibition of an associated avoidance response, is considered the key element in the cognitive behavioral therapy of anxiety disorders [77, 78].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [78]
The cited source says what the claim attributes to it.
In the citing paper
“Practicing these skills in different fear-inducing contexts supports generalization of inhibitory learning and stronger extinction of fear responses [78].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [78]
In the citing paper
“CBT, focusing on exposure to feared cues to promote extinction learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014), continues to be the most widely used and most strongly validated psychotherapeutic treatment for both youth and adult anxiety disorders (Barry, Yeung, & Lau, 2018;Kodal et al., 2018).”
From Novel pharmacological targets in drug development for the treatment of anxiety and anxiety-related disorders (2019) · cites this paper as Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014
In the citing paper
“Existing interventions for anxiety and depression emphasize negative affect reduction as the central treatment goal.”
From Upregulating the positive affect system in anxiety and depression: Outcomes of a positive activity intervention: Taylor et al. (2017) · cites this paper as [17]
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Gruner, N. G., Cullen, J. M., Crosby, J. M., DeCross, S. N., Mathes, B., Garner, L., Gironda, C., Hu, Y., Krompinger, J. W., Elias, J. A., et al. (2024) · Journal of Cognitive Psychotherapy · doi:10.1891/jcp-2022-0033
Broman-Fulks, J. J., Bergquist, J. J., Hall, C. A., Thomas, K., & Kelso, K. C. (2023) · Journal of Cognitive Psychotherapy · doi:10.1891/jcpsy-d-20-00056
Avoidance: Exposure Therapy Informed Communication for Serious Illness Care.
Chammas, D., Jackson, V., & Brenner, K. O. (2026) · Journal of Palliative Medicine · doi:10.1177/10966218261431684
“…HPM, Ali ’ s team can mindfully select and employ techniques, skills, and strategies that align with evidence-based exposure therapy principles, 4,13,15 such as the following: (1) Progressive disclosure: Introducing challenging information in incremental doses may reduce distress and enhance…”
Metadata
- Authors
- Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B.
- Affiliations
- University of California, Los Angeles (US)
- KU Leuven (BE)
- Corresponding author
- Craske, Michelle G.
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2014-07
- Volume
- 58
- Pages
- 10-23
- ISSN
- 0005-7967 (ISSN-L)
- PMC
- PMC4114726
- OpenAlex
- W2057906075
- Semantic Scholar
- 0d5de00a9991db7a0f004d29efca3e1c6f367c0f
- Cited by
- 2,339
- References
- 108
- Citations by year
- 2026: 304 · 2025: 247 · 2024: 265 · 2023: 196 · 2022: 233 · 2021: 245 · 2020: 213 · 2019: 175 · 2018: 156 · 2017: 124 · 2016: 107 · 2015: 59 · 2014: 12
- FWCI
- 139.66
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Lirias (submittedVersion, other-oa)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Institute of Mental Health (R34MH101359, R21MH081299, R01MH065651)
- National Human Genome Research Institute (T32HG002536)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Life Sciences › Neuroscience › Cognitive Neuroscience › Memory and Neural Mechanisms
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- exposure therapy, inhibitory learning, extinction learning, anxiety disorders, treatment optimization, expectancy violation, safety signals, retrieval cues, affect labeling, obsessive-compulsive disorder, post-traumatic stress disorder, social anxiety disorder, specific phobia, panic disorder
- MeSH terms
- Adult, Anxiety Disorders, Extinction, Psychological, Female, Humans, Implosive Therapy, Inhibition, Psychological, Learning, Male
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