A Multilevel Examination of an Inhibitory Retrieval Approach to Exposure: Differentiating the Unique and Combined Effects of Multiple-Context and Multiple-Stimulus Cues

Background and Objectives A proposed strategy for attenuating the return of fear is conducting exposure therapy in multiple contexts (e.g., different locations), which is believed to enhance the generalizability of safety learning. Although conducting exposure in multiple contexts can be differentiated from conducting exposure with multiple stimuli, the two strategies are often conflated. Furthermore, researchers have not yet determined whether one of these strategies, or a combination thereof, is most effective in attenuating fear renewal. Methods Accordingly, the present treatment-analogue study examined the unique and combined effects of multiple-context and multiple-stimulus imagery-based exposure manipulations on threat expectancy, behavioral approach/anxiety, and attentional bias for threat over Zoom. Community adults (N=134) who met diagnostic criteria for snake phobia were randomized to exposure to a single snake in multiple environmental contexts (MC), exposure to multiple snakes in a single environmental context (MS), or exposure to multiple snakes in multiple environmental contexts (MS/MC). Results Results revealed significant reductions in threat expectancy and behavioral anxiety, but not attentional bias for threat in all three groups. However, behavioral approach declined over the course of exposure in the MS/MC condition but remained stable in the MC and MS conditions. There were no significant group differences in behavioral approach/anxiety or attentional bias at a one-week follow-up. However, participants in the MC condition reported lower threat expectancy at a one-week follow-up than the other groups and this group difference was partially mediated by lower mean distress during exposure. Conclusions Implications of these findings for the inhibitory retrieval theory are discussed.