Gain through pain: Augmenting in vivo exposure with enhanced attention to internal experience leads to increased resilience to distress.

Recent variants of exposure therapy ask clients to directly engage with the distress associated with avoided experiences in order to become more resilient to future anxiety-provoking situations. In this study, we consider how this engagement impacts behavioral willingness. Forty-eight participants with high fear of cockroaches completed in vivo exposures while either mindfully attending externally to the feared object (Ext), or to both the object and their internal distress (Int/Ext). While both groups showed improvement, behavioral, subjective and physiological measures revealed different patterns of change. Immediate testing showed that participants in the Ext condition improved more in subjective distress, with no other differences between groups. A second testing a week later in an ecologically valid environment showed that participants the Int/Ext intervention continued to improve behaviorally, regardless of their reported subjective discomfort. These findings highlight the importance of explicit engagement with distress during exposures, that forego immediate subjective relief for long-term behavioral improvement.