Implosive Therapy

Abstract

Implosive therapy is an exposure-based treatment for anxiety that MeSH classifies under psychologic desensitization: it extinguishes a conditioned fear by having the patient confront an imagined version of the feared situation at full intensity, without escape, until the anxiety subsides. Developed by Thomas Stampfl in the late 1950s and formalized with Donald Levis in 1967, it operationalizes two-factor theory, in which fear is acquired by classical conditioning and then preserved by the avoidance that blocks its extinction. Where Wolpe's systematic desensitization dismantles fear gradually and keeps anxiety low, implosion evokes maximum anxiety and relies on non-reinforced exposure. This article sets out its learning theory, its imaginal flooding procedure, and the emotional-processing and inhibitory-learning accounts that reinterpreted why prolonged exposure reduces fear — the empirically supported descendant that kept the intensive exposure and dropped implosion's unsupported psychodynamic cues.

Keywords: implosive therapy, flooding, exposure therapy, extinction, two-factor theory

What Implosive Therapy Is

Implosive therapy is a therapeutic technique, not a theory or a disorder, and MeSH files it in the exposure family under psychologic desensitization, the broad class of behavior therapy methods that reduce fear by arranged contact with what is feared. Its defining move is intensity. Rather than approaching a feared situation by cautious degrees, the patient is asked to confront it at once and in full, holding the most frightening version of the scene in imagination while the therapist blocks any retreat, and to stay with it until the anxiety it provokes rises, peaks, and falls of its own accord (Stampfl & Levis, 1967).

The name captures the design. The patient is asked to let the fear 'implode' — to experience it at maximum strength in a safe consulting room where no actual harm can follow — on the reasoning that a fear repeatedly evoked and never reinforced by a real bad outcome must weaken. The method is therefore built around a single learning process, extinction: the decline of a conditioned response when the conditioned stimulus is presented again and again without the aversive event that once accompanied it (Levis & Hare, 1977).

What sets implosion apart from ordinary exposure is not the exposure but the scenes. Stampfl held that a lasting fear is attached not only to the obvious external trigger but to a set of hidden internal cues — bodily sensations, and hypothesized symbolic or psychodynamic themes such as aggression, rejection, or guilt — and that a complete treatment must present these too, scripted into deliberately exaggerated imagined narratives (Stampfl & Levis, 1967). This psychodynamic content is the historically distinctive, and most contested, feature of the technique, and separating it from the plain intensive exposure it was wrapped in became the central empirical question about the method.

Origins and Two-Factor Theory

Implosive therapy grew out of the learning theory that dominated mid-century clinical psychology, and specifically out of an attempt to explain a stubborn clinical fact: why phobic fears do not fade on their own even though the feared objects almost never cause harm. The answer the field reached was Mowrer's two-factor theory (Mowrer, 1951), and implosion is in effect that theory turned into a treatment (Levis & Hare, 1977).

The two factors are two kinds of learning. First, a neutral stimulus becomes frightening through classical conditioning: paired once or repeatedly with something aversive, it comes to evoke fear by itself. Second, the person learns to escape or avoid that stimulus, and because each successful avoidance removes the fear, the avoidance is negatively reinforced and grows stronger. The tragedy built into this arrangement is that avoidance is self-perpetuating. By fleeing the feared stimulus the person also removes every opportunity for the fear to extinguish, since extinction requires staying in contact with the conditioned stimulus while nothing bad happens. Avoidance thus buys immediate relief at the cost of preserving the fear indefinitely (Stampfl & Levis, 1967).

Implosion attacks exactly this trap. If avoidance maintains the fear by preventing extinction, then the therapeutic task is to prevent the avoidance: to hold the patient in full contact with the feared cues, in imagination, long enough and intensely enough that the conditioned fear response can run its course and decline unreinforced. The maximal intensity is not gratuitous — it is meant to ensure the relevant fear cues are fully activated, on the premise that a cue which is not evoked cannot be extinguished. This is the theoretical reason implosion courts the very anxiety that every other instinct, and every avoidance-based coping strategy, is organized to escape (Levis & Hare, 1977).

The Method in Practice

A course of implosive therapy begins not with exposure but with assessment. The therapist works out the patient's fear cues, sorting them into the obvious external triggers — a dog, a height, a crowded room — and the hypothesized internal and symbolic cues Stampfl believed lay beneath them. From this the therapist scripts a series of imaginal scenes, and here the method's distinctive character shows: the scenes are written to be as vivid and frightening as possible, escalating past realism into deliberately catastrophic and symbolic imagery (Stampfl & Levis, 1967).

In the session the patient closes their eyes and is asked to imagine the scene as fully as they can while the therapist narrates it, adding detail and pressing the imagery toward its most distressing form. Crucially, the therapist does not offer reassurance or let the patient soften or leave the scene; the whole point is to sustain high anxiety without the escape that would ordinarily terminate it. The scene is held until the patient's anxiety, having risen to a peak, begins to fall — the observable sign that extinction is underway within the session. Repeated across scenes and sessions, this within-session decline is expected to carry over into a lasting between-session reduction in the fear (Levis & Hare, 1977).

The reliance on imagination was partly practical. Many of the cues Stampfl wanted to present — symbolic themes, catastrophic outcomes, physical harm — cannot be arranged in reality, and imaginal presentation let the therapist evoke them at full strength safely. This is the same imaginal-flooding logic that later structured the trauma-memory work of prolonged exposure, where the feared material is a memory that cannot and should not be recreated in the world (Foa & McLean, 2016). The technique's demand that the patient tolerate deliberately amplified distress also made it, from the beginning, a hard treatment to deliver well and an uncomfortable one to receive, which shaped both its clinical reception and its dropout profile (Boudewyns & Shipley, 1983).

Flooding, Implosion, and Desensitization

Implosive therapy is best understood by contrast with its neighbors in the exposure family, because the family divides along two axes: how intense the exposure is, and what content it presents. On intensity, the sharp opposition is with Wolpe's systematic desensitization. Desensitization dismantles a fear gradually, teaching the patient deep relaxation and then walking up a hierarchy of ever-more-feared situations so slowly that anxiety is kept near zero throughout, on the principle that relaxation reciprocally inhibits fear (Wolpe, 1958). Implosion inverts every term of this: no relaxation, no hierarchy, and a deliberate leap to the top of the fear scale rather than a careful climb.

That intensive approach implosion shares with flooding, and the two terms are often used loosely as synonyms. The useful distinction is one of content and rationale rather than intensity. Flooding, as developed and tested in Britain, means prolonged exposure to realistic feared stimuli — real or imagined — at full strength, and stops there. Implosion adds Stampfl's extra ingredient: the hypothesized symbolic and psychodynamic cues, and scenes exaggerated past realism to present them. Every implosion is a kind of flooding, but not every flooding is implosion, and the difference is precisely the psychodynamic content that flooding declines to script (Levis & Hare, 1977).

This distinction became the field's decisive test. If intensive exposure works because of extinction, the imagined psychodynamic content should be dispensable; if implosion's theory is right, the content should add something. The controlled comparison that bore most directly on the question found flooding and desensitization both effective, with flooding-type intensive exposure at least as good as the gradual method and faster for some phobias, and no evidence that Stampfl's elaborated symbolic scenes outperformed plain realistic exposure (Marks, Boulougouris & Marset, 1971). The verdict that emerged over the following decade was that the exposure carried the effect and the psychodynamic scene construction did not, which is why the empirically supported descendant of the tradition kept the former and dropped the latter.

Why Exposure Works: Emotional Processing and Inhibitory Learning

Stampfl's own explanation of implosion was extinction plus the activation of hidden cues, but the mechanism question outgrew that framing, and two later theories reorganized how the field understands every exposure treatment. The first was emotional-processing theory, which recast fear as a structure in memory — a network linking the feared stimulus, the fear responses, and the meanings attached to them. On this account exposure works by two conditions: the fear structure must be activated, and it must then receive information that is incompatible with it, chiefly the experience that the feared consequence does not occur. Within-session and between-session decline in fear were taken as the markers that this corrective processing had happened (Foa & Kozak, 1986). Emotional-processing theory gave implosion's twin demands — full activation of the fear, and staying until it falls — a cleaner rationale than two-factor theory had, and it was the theoretical bridge from implosion to modern prolonged exposure. It built on Rachman's earlier account of emotional processing as the absorption of disturbing emotional experiences until they cease to intrude (Rachman, 1980).

The second theory revised the mechanism again. Inhibitory-learning models, drawing on the animal-conditioning finding that extinction does not erase the original fear memory but overlays it with a new, competing inhibitory memory, argued that exposure's job is to build and strengthen that new learning rather than to reduce anxiety within the session (Craske et al., 2008). This reframing matters because it detaches success from the within-session habituation that implosion and emotional-processing theory both treated as the sign of change: on the inhibitory-learning view, how much fear falls during a session predicts long-term outcome poorly, and the therapeutic aim is instead to maximize the mismatch between what the patient expects and what happens, and to make the new safety learning retrievable across contexts (Craske et al., 2014). The clinical translation of these ideas to practice reshaped how exposure is now designed and delivered (Jacoby & Abramowitz, 2016).

The Evidence Base

The evidence about implosive therapy separates into two questions that its history kept tangled: does intensive exposure work, and does implosion's distinctive psychodynamic content add anything. On the first, the answer is a clear yes, and it is the reason the tradition survives. Controlled trials from the early 1970s onward established that flooding-type intensive exposure produced reliable fear reduction, comparable to and sometimes faster than systematic desensitization, and the broader exposure literature that grew from this work is among the best-supported in clinical psychology (Marks, Boulougouris & Marset, 1971). Modern meta-analyses of cognitive behavioral and exposure-based treatments for anxiety disorders confirm medium-to-large effects against control conditions, with exposure the common active ingredient (Carpenter et al., 2018).

On the second question the verdict went against Stampfl. The elaborated symbolic and psychodynamic scenes that distinguished implosion from plain flooding were never shown to improve outcomes, and dismantling comparisons found that realistic exposure to actual fear cues did as well or better than exposure to hypothesized underlying cues (Levis & Hare, 1977). The practical consequence was decisive: the field kept the intensive, avoidance-blocking exposure and discarded the psychodynamic theory of cues, and the treatment that carried the method forward — prolonged exposure for post-traumatic stress and the exposure protocols for other anxiety disorders — is implosion's extinction logic without its symbolic scene construction (Foa & McLean, 2016).

The remaining reservations about intensive exposure concern tolerability and reach rather than efficacy. Because the method deliberately provokes high anxiety, it asks more of patients than gradual approaches and has historically carried higher dropout, and its outcomes vary with how completely the fear is activated and how thoroughly avoidance is blocked (Bohnlein et al., 2020). These are the variables the inhibitory-learning program now tries to optimize, which is why the mechanistic and the clinical strands of the exposure literature have converged on the same practical agenda.

Implosive Therapy in Motion

The three demonstrations below make the logic of the method manipulable. The first is the extinction-versus-avoidance engine at the heart of two-factor theory, showing how staying in contact with a feared cue lets fear decline while escaping preserves it. The second contrasts the intensive approach of implosion with the graded approach of desensitization on a single anxiety-over-time plot. The third makes the evidence base concrete, translating a meta-analytic effect size into the share of untreated patients the average treated patient exceeds, and showing how that figure moves with the comparison condition.

Extinction versus avoidance

Conditioned fear cue presented. Stay in contact, or escape?

Current fear: 100.0 / 100  ·  stays: 0  ·  escapes: 0

Each stay is a non-reinforced exposure that lets the fear extinguish a step (a 20% reduction); each escape brings relief but leaves the fear undiminished for the next trial. Only the stays move the number down — the trap the therapy is built to break.

The extinction demonstration puts two-factor theory under the reader's hand. Each trial presents the conditioned fear cue; choosing to stay lets the fear response decline a step through non-reinforced exposure, while choosing to escape delivers immediate relief but leaves the fear at full strength for the next trial. It makes visible the trap the therapy is built to break: escape feels better now and keeps the fear forever, while staying feels worse now and is the only thing that extinguishes it.

Intensive versus graded exposure

Peak anxiety reached: 90 ·  endpoint: 5

Implosion starts at the maximum and extinguishes from the top; desensitization holds anxiety near a low target (dashed line) and declines gently. The two routes reach a similar endpoint — a short intense path many find hard to tolerate, or a long gentle one that keeps distress down.

The approach demonstration contrasts the two exposure strategies directly. Setting the method to implosion starts the anxiety at its maximum and lets it extinguish from the top; setting it to desensitization climbs a hierarchy so gradually that anxiety stays low throughout. The two curves reach a similar endpoint by opposite routes, which is the whole clinical choice the exposure family offers: a short intense path that many find hard to tolerate, or a long gentle one that keeps distress down.

Exposure efficacy by comparator

The average treated patient does better than 84% of the comparison group.

The treatment does not change across the buttons; only the comparator does. A large headline effect against an untreated control shrinks toward the 50% no-difference line when the comparison is an active alternative — which is why an effect size is uninterpretable until its comparator is named.

The efficacy demonstration makes the evidence base tangible and its interpretation cautious. Choosing the comparison condition intensive exposure is tested against — an untreated control, or an active alternative such as gradual desensitization — sets a standardized effect size and converts it into the percentage of control patients the average treated patient outperforms. It shows both why the method is called effective and why the size of that claim depends entirely on what it is measured against.

Worked Example

Begin with the extinction engine the first demonstration builds. A conditioned fear starts at a strength of 100 on an arbitrary scale. Model each non-reinforced exposure — each trial the patient stays in contact with the cue — as reducing the remaining fear by a fixed extinction fraction of 20%, the standard geometric form of an extinction curve. After one stay the fear is 100 × 0.8 = 80; after two, 80 × 0.8 = 64; after three, 51.2; after four, 40.96; after five, 32.77. Five sustained exposures have cut the fear to roughly a third of its starting value, and the decline is steep at first and then flattens, the characteristic shape of extinction.

Now introduce avoidance. Suppose that on the third trial the patient escapes instead of staying. Escape terminates the exposure before any extinction occurs, so the fear does not fall on that trial — it remains at its pre-trial value of 64 — and, because escape is negatively reinforced by the relief it brings, the fear available to drive the next avoidance is undiminished. Two stays followed by an escape leave the fear at 64 rather than the 51.2 that a third stay would have produced; the single avoidance has erased one exposure's worth of progress and, repeated, would hold the fear near its ceiling indefinitely. This is the arithmetic of the trap: only the stays reduce the number, and every escape is a step not taken.

Now the evidence base. A standardized effect size (Cohen's d) can be read as U3, the fraction of control-group patients the average treated patient exceeds, where U3 is the standard normal cumulative distribution evaluated at d. Against an untreated control an illustrative d = 1.00 gives U3 = 0.841, so the average treated patient does better than about 84% of untreated controls — a large, headline effect. Against an active alternative such as gradual desensitization an illustrative d = 0.15 gives U3 = 0.560, about 56%, barely above the coin-flip value of 50% that marks no difference at all. The treatment has not changed between the two rows; only the comparator has, which is why an effect size for intensive exposure is uninterpretable until the condition it was measured against is named (Carpenter et al., 2018).

Discussion

Implosive therapy occupies an unusual place in the history of behavior therapy: a treatment whose core procedure was vindicated and whose founding theory was discarded, so that its success and its refutation are the same story told from two sides. The procedure — intensive, imaginal, avoidance-blocking exposure sustained until fear declines — proved to be one of the most robust interventions in clinical psychology, and it is alive today in prolonged exposure and the exposure protocols that anchor evidence-based treatment of anxiety and trauma (Foa & McLean, 2016). Almost every patient who undergoes modern exposure therapy is receiving the extinction logic Stampfl and Levis built the method around.

What did not survive was the elaborated theory of cues. Stampfl's conviction that lasting fears are anchored to hypothesized symbolic and psychodynamic themes, and that scenes must be scripted to evoke them, was the feature that gave implosion its name and its distinctiveness, and it is the feature the evidence failed to support (Levis & Hare, 1977). The dismantling of implosion is a clean example of how behavior therapy policed its own claims: a technique packaged with an untested theory was subjected to controlled comparison, the effective component was separated from the inert one, and the field kept only what the trials supported.

The wider significance for cognitive psychology lies in what the mechanism debate became. Implosion was explained first by two-factor conditioning, then by emotional processing, then by inhibitory learning, and each reframing changed not the observation — that prolonged exposure without escape reduces fear — but the account of why, and with it the advice about how to deliver exposure best (Craske et al., 2014). The trajectory from Stampfl's imploded scenes to the inhibitory-learning designs of the present is a case study in a therapy outliving the theory that produced it, carried forward by a robust effect in search of a correct explanation.

Current Directions

The most active current work descends directly from the inhibitory-learning turn: the effort to specify what makes exposure stick and to redesign it accordingly. Rather than treating within-session fear reduction as the goal, this program aims to maximize the mismatch between expected and actual outcomes, to vary the stimuli and contexts of exposure so the new safety learning generalizes, and to reduce the retrieval failures that produce relapse — a set of prescriptions now being translated from the laboratory into clinical protocols across the anxiety disorders (Jacoby & Abramowitz, 2016).

A second direction is the search for the conditions under which intensive exposure succeeds or fails. Systematic reviews of the predictors of exposure outcome for specific phobia have begun to map how completely the fear must be activated, how thoroughly avoidance and safety behaviors must be blocked, and which patient and delivery factors move the result — the empirical questions implosion raised but could not answer with mid-century methods (Bohnlein et al., 2020). The recurring finding that avoidance and incomplete activation undermine exposure is a modern confirmation of the mechanism Stampfl designed the method to defeat.

A third strand concerns tolerability and reach. Because intensive exposure asks patients to endure high anxiety, work continues on formats that preserve the extinction logic while improving acceptability and access — from massed and intensive scheduling to technology-assisted and virtual delivery — extending the tradition's core procedure to patients and settings the original consulting-room method could not serve. Across all three strands the common movement is from asking whether intensive exposure works toward specifying, measuring, and optimizing the learning through which it is supposed to work.

Common Misconceptions

Implosive therapy and flooding are the same thing.

They overlap but are not identical. Both use prolonged, intensive exposure, but implosion adds Stampfl's hypothesized symbolic and psychodynamic cues and scenes exaggerated past realism, whereas flooding presents realistic feared stimuli and stops there. Every implosion is a flooding; not every flooding is implosion (Levis & Hare, 1977).

Implosion works by exhausting or overwhelming the patient.

The mechanism is extinction, not exhaustion. The fear declines because the conditioned cue is presented repeatedly without the aversive outcome that once followed it, allowing the fear response to weaken unreinforced; the intensity serves to activate the fear fully, not to wear the patient down (Stampfl & Levis, 1967).

The imagined psychodynamic scenes are what make it work.

Controlled comparisons found no advantage for implosion's elaborated symbolic content over plain realistic exposure; the intensive avoidance-blocking exposure carried the effect, and the psychodynamic scene construction did not, which is why its descendants dropped it (Marks, Boulougouris & Marset, 1971).

Because the fear drops during a session, the session is what cured it.

Inhibitory-learning research finds that within-session fear reduction predicts long-term outcome poorly; lasting improvement depends on new inhibitory learning that is retrievable across contexts, not on how far anxiety fell in the room (Craske et al., 2014).

Glossary

Avoidance.

A response that removes or prevents contact with a feared stimulus; negatively reinforced by the relief it brings and, in two-factor theory, the mechanism that preserves a fear by preventing its extinction.

Classical conditioning.

The learning process by which a neutral stimulus paired with an aversive event comes to evoke fear by itself; the first factor in the two-factor account of how phobias are acquired.

Conditioned stimulus.

A once-neutral stimulus that, through conditioning, has come to elicit a fear response; the cue that exposure presents repeatedly without reinforcement so the response can extinguish.

Emotional processing theory.

Foa and Kozak's account in which fear is a memory structure that exposure changes by activating it and supplying information incompatible with it, chiefly that the feared outcome does not occur.

Exposure therapy.

The family of behavior-therapy methods that reduce fear through arranged contact with feared stimuli; implosion, flooding, and systematic desensitization are its members.

Extinction.

The decline of a conditioned response when the conditioned stimulus is presented repeatedly without the aversive event that once accompanied it; the learning process implosion is designed to force.

Flooding.

Prolonged exposure to realistic feared stimuli at full intensity; distinguished from implosion by presenting actual rather than hypothesized symbolic cues.

Habituation.

The within-session decline of a fear response with sustained exposure; long treated as the sign that exposure is working, though inhibitory-learning research questions its link to lasting outcome.

Imaginal exposure.

Confrontation with a feared scene in imagination rather than reality, used when the feared material cannot or should not be recreated in the world; the core delivery mode of implosive therapy.

Implosive therapy.

An intensive, imaginal, avoidance-blocking exposure treatment developed by Stampfl and Levis that presents maximally feared and symbolically elaborated scenes until the conditioned fear extinguishes.

Inhibitory learning.

The view that extinction does not erase the fear memory but overlays it with a new, competing inhibitory memory, and that exposure's goal is to build and make retrievable that new safety learning.

Prolonged exposure.

The empirically supported descendant of implosion, most established for post-traumatic stress, that keeps intensive imaginal and in-vivo exposure while dropping the psychodynamic scene construction.

Psychodynamic cues.

The hypothesized symbolic themes — aggression, rejection, guilt — that Stampfl believed underlay lasting fears and scripted into implosive scenes; the method's distinctive and unsupported feature.

Systematic desensitization.

Wolpe's graded exposure method that pairs deep relaxation with a slowly ascending fear hierarchy to keep anxiety low; the gradual opposite of implosion's intensive approach.

Two-factor theory.

Mowrer's account in which fear is acquired by classical conditioning and then maintained by avoidance that is negatively reinforced; the theoretical basis of implosive therapy.

Key Researchers

Jonathan S. Abramowitz. University of North Carolina at Chapel Hill clinical psychologist whose critical review of inhibitory-learning exposure translated the modern mechanistic account of how exposure works into clinical practice for anxiety and obsessive-compulsive disorders. Google Scholar - Wikipedia - Wikidata - Faculty page

Michelle G. Craske. UCLA professor of psychology and psychiatry whose inhibitory-learning model reframed how exposure treatments including flooding work, shifting the emphasis from fear habituation to the building of new inhibitory learning. ORCID - Google Scholar - Wikipedia - Wikidata

Edna B. Foa. University of Pennsylvania clinical psychologist whose emotional-processing theory of fear supplied the dominant modern account of how exposure reduces fear, and who developed prolonged exposure, implosion's empirically supported descendant. Google Scholar - Wikipedia - Wikidata

Isaac M. Marks. Emeritus professor at the Institute of Psychiatry, King's College London, whose controlled crossover trial of flooding versus desensitization was among the first rigorous clinical tests of intensive exposure. Wikipedia - Wikidata

Joseph Wolpe. Psychiatrist whose reciprocal-inhibition account and systematic desensitization defined the gradual-exposure tradition against which implosion's intensive, maximal-anxiety approach was explicitly contrasted. Wikipedia - Wikidata

Frequently Asked Questions

What is implosive therapy?
It is an intensive exposure treatment for anxiety in which the patient confronts the feared situation, usually in vivid imagination, at maximum intensity and without escape until the conditioned fear extinguishes on its own (Stampfl & Levis, 1967).

How is implosive therapy different from systematic desensitization?
They are opposites within the exposure family. Systematic desensitization reduces fear gradually with relaxation and a slowly ascending hierarchy that keeps anxiety low, while implosion leaps to maximum anxiety and relies on non-reinforced exposure to extinguish the fear (Wolpe, 1958).

Is implosive therapy the same as flooding?
They overlap. Both use prolonged intensive exposure, but implosion adds Stampfl's hypothesized symbolic and psychodynamic cues and deliberately exaggerated scenes, whereas flooding presents realistic feared stimuli only (Levis & Hare, 1977).

What theory is implosive therapy based on?
It operationalizes two-factor theory, in which a fear is acquired by classical conditioning and then maintained by avoidance; implosion blocks the avoidance so the conditioned fear can extinguish (Stampfl & Levis, 1967).

Does implosive therapy actually work?
The intensive, avoidance-blocking exposure at its core is highly effective and among the best-supported interventions in clinical psychology, though its distinctive psychodynamic scene content was never shown to add benefit (Marks, Boulougouris & Marset, 1971).

Why does confronting a fear at full intensity reduce it?
Because the feared cue is presented repeatedly without the aversive outcome that once accompanied it, the conditioned fear response weakens through extinction; modern accounts add that new inhibitory learning competes with and suppresses the original fear (Craske et al., 2014).

What happened to implosive therapy?
Its extinction logic was kept and its psychodynamic theory discarded; the method survives as prolonged exposure and the exposure protocols for anxiety disorders, which retain the intensive exposure and drop the symbolic scene construction (Foa & McLean, 2016).

Is implosive therapy safe or harmful?
It provokes high anxiety by design, which makes it demanding and historically associated with higher dropout, but it does not cause the feared harm; the distress is temporary and the safety of the consulting room is what allows the fear to extinguish (Bohnlein et al., 2020).

References