Seeing the Worst or Saying the Words? A Multilevel Comparison of Occasional Reinforcement and Affect Labeling as Strategies to Augment an Imagery-Based Exposure Intervention

Research has shown that some individuals do not benefit from exposure therapy and for those who do, fear can return. Occasional reinforcement, which involves intermittently reinforcing the feared outcome during exposure, and affect labeling, in which individuals describe their current affective state during exposure, are two inhibitory retrieval strategies that have shown promise for augmenting exposure interventions. Yet, it remains unclear whether these strategies differ in their efficacy for attenuating return of fear across multiple levels of analysis. Accordingly, the present treatment-analogue experiment examined the effects of a multi-session imagery-based exposure manipulation that included reminders of the feared outcome or prompts to label one’s affective experience in a phobic sample on threat expectancy, behavioral avoidance, and attentional bias for threat. Community adults (N = 136) who met diagnostic criteria for snake phobia were randomized to a single-cue video exposure alone condition (S), a multiple-cue video exposure condition that occasionally reinforced the feared outcome (i.e., snake bite; FO), or a multiple-cue video exposure condition that instructed participants to label their affective response (AL). Results revealed significant reductions in threat expectancy and behavioral avoidance, but not attentional bias for threat, for all three groups. Although there were no significant group differences in threat expectancy and attentional bias for threat at a 1-week follow up, those in the FO condition completed significantly more BAT steps than the AL group and this group difference was partially mediated by distress variability and within-session fear reduction. The implications of these findings for the inhibitory retrieval theory are discussed.