Exposure Therapy with Children and Adolescents 9781462539581, 1462539580

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ebook THE GUILFORD PRESS

EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

Also Available Emotion Regulation in Children and Adolescents: A Practitioner’s Guide Michael A. Southam-Gerow

Exposure Therapy with Children and Adolescents

Michael A. Southam-Gerow

The Guilford Press New York

London

Copyright © 2019 The Guilford Press A Division of Guilford Publications, Inc. 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com All rights reserved Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number: 9 8 7 6 5 4 3 2 1 LIMITED DUPLICATION LICENSE These materials are intended for use only by qualified mental health professionals. The publisher grants to individual purchasers of this book nonassignable permission to reproduce Form 10.1. This license is limited to you, the individual purchaser, for personal use or use with individual clients. This license does not grant the right to reproduce this material for resale, redistribution, electronic display, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides for lectures, workshops, webinars, or therapy groups, whether or not a fee is charged). Permission to reproduce this material for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications. The author has checked with sources believed to be reliable in his efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the author, nor the editor and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources.

Library of Congress Cataloging-in-Publication Data Names: Southam-Gerow, Michael A., author. Title: Exposure therapy with children and adolescents / Michael A. Southam-Gerow. Description: New York : The Guilford Press, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2019007465 | ISBN 9781462539581 (hardback) Subjects: LCSH: Anxiety in children—Treatment. | Anxiety in adolescence—Treatment. | Exposure therapy. | BISAC: PSYCHOLOGY / Psychopathology / Anxieties & Phobias. | MEDICAL / Psychiatry / Child & Adolescent. | SOCIAL SCIENCE / Social Work. | PSYCHOLOGY / Psychotherapy / Child & Adolescent. Classification: LCC RJ506.A58 S658 2019 | DDC 618.92/8522—dc23 LC record available at https://lccn.loc.gov/2019007465

About the Author

Michael A. Southam-Gerow, PhD, is Professor of Psychology at Virginia Commonwealth University. His research focuses on the dissemination and implementation of psychological treatments for mental health problems in children and adolescents. He also studies emotion processes (such as emotion regulation) in children and adolescents, and treatment integrity. Dr. Southam-Gerow is a consultant for PracticeWise, a company offering training to therapists and agencies in evidence-informed approaches to children’s mental health care. He has served as Associate Editor for the Journal of Consulting and Clinical Psychology and the Journal of Clinical Child and Adolescent Psychology, has published dozens of scholarly papers, and is author of Emotion Regulation in Children and Adolescents: A Practitioner’s Guide.

v

Acknowledgments

T

his is the easiest section of a book to write, as I am constantly reminded of how grateful I am for the guidance, counsel, and friendship of so many individuals in my life. Having the opportunity to thank them gives me great pleasure. I want to start by thanking The Guilford Press and my editor, Kitty Moore, for believing that I could and should write another book. Kitty’s enthusiasm has been a beacon for me. I also owe a debt to Barbara Watkins for her close and helpful reading of an earlier draft of this book. Relatedly, I want to thank Anne Marie Albano and John Piacentini for encouraging me to write this particular book. You two are superstars in the field and your belief in me was a great inspiration. And thanks for not finishing the book so I could take a stab at it! I am passionate about the topic of exposure and I owe a lot of that passion to my mentors and colleagues who trained me and worked alongside me during my training. These include my graduate school mentor Phil Kendall, with whom I am grateful to continue collaborating. It also includes my other mentor in graduate school, Jay Efran, who taught me so much about how to be a therapist and a professional. I also have to thank my graduate school colleagues in the Child and Adolescent Anxiety Disorders Clinic at Temple University, who taught me all I know about therapy with children: Serena Ashmore-Callahan, Erika Brady, Tamar Chansky, Brian Chu, Ellen Flannery-Schroeder, Elizabeth Gosch (who first taught me how to do cognitive-behavioral therapy [CBT] for anxiety), Aude Henin, Martha Kane, Amy Krain, Abbe Marrs-Garcia, Suzie Panichelli-Mindel, and Melissa Warman. I cannot imagine better folks with whom to have gone through the crazy experience that is graduate school. vii

viii Acknowledgments

I also want to express my gratitude to my students, past and current, who have worked with me treating anxious children, adolescents, and adults here in Richmond, Virginia, for the past 15 years, including students I advised: Alyssa Ward, Kim Goodman, Ruth Brown, Shannon Hourigan, Alexis Quinoy, Cassidy Arnold, Carrie Bair, and Adriana Rodriguez (all PhDs now), and Julia Cox, Selamawit Hailu, Natalie Finn, and Sandra Yankah (all heading toward their PhDs), as well as students too numerous to list whom I have supervised at our anxiety clinic at Virginia Commonwealth University (VCU). I am pleased to thank a few VCU colleagues. First, thanks to my friend and the cofounder of the anxiety clinic at VCU, Scott Vrana. What an amazing and fun journey it was, from a little start-up back in the early 2000s to the fixture in the community it is now. Thanks too to my VCU colleague Bryce McLeod, who has been a great partner in research for the past decade—I can’t wait to raise a mug of beer to more years of collaboration! In addition, I am thankful for the hundreds of therapists I have trained in Australia, California, Hawaii, Kentucky, Maine, Maryland, Massachusetts, Minnesota, New York, South Carolina, Virginia, and Washington, DC, whose work has inspired me and taught me so much about clinical work with children and adolescents. I also want to thank the PracticeWise, LLC, team, a group of amazing people who make an immense difference in the world of child and adolescent behavioral health services: Ceth Ashen, Kim Becker, Adam Bernstein, Teri Bourdeau, Angela Chiu, Bruce Chorpita, Taya Cromley, David Daleiden, Eric Daleiden, Charmaine Higa-McMillan, Andrea Letamendi, Michelle Levy, Allison Love, Brad Nakamura, Kelly O’Brien, Jennifer Podell, Nicole Starace, and Alyssa Ward (again!). I also want to give a shout-out to the hui: Kim Becker, Adam Bernstein, Angela Chiu, Bruce Chorpita, Eric Daleiden, Chad Ebesutani, Charmaine Higa-McMillan, Brad Nakamura, and Cameo Stanick. Having regular contact with friends and colleagues like you has been important to me and kept me sane. I also want to single out two folks who are particularly important to mention in relation to this book. First, Phil Kendall, my graduate school advisor and the Zen master of CBT. I am so glad I landed in his lab in the early 1990s. It is not an overstatement to say that had I not worked with Phil, I would not be writing this book. Learning from one of the pioneers in the use of CBT with children was the best and luckiest thing that happened to me professionally. I also want to thank my good friend Bruce Chorpita, a giant in the field. I still remember the day we talked



Acknowledgments ix

over lunch in Boston in the early 2000s, learning just how much we had in common in terms of our vision for the field. I don’t think either of us would have predicted that we would be launching such a long-lasting and productive collaboration. Nor did we know that from that meeting would blossom such an incredible friendship, leading to so many laughs and such a profound depth of support. Thank you, Bruce! I have also been fortunate enough to receive financial support from federal sources (the National Institute of Mental Health, the National Institute on Drug Abuse, and the Institute of Education Sciences) and from VCU over these past 17 years. I am particularly grateful to Joel Sherrill, Serene Olin, and Heather Ringeisen, whose encouragement early in my career made a huge difference. On a personal level, I want to thank my parents, Bob and Carolyn. I was an independent young person who charged ahead, sometimes without good planning, so raising me was not easy at times. They encouraged me to write at an early age, including facilitating my becoming the editor of a neighborhood newspaper when I was 10 years old. Writing became a passion that I have maintained for more than 40 years. I also want to thank my children, Zen and Evelyn, who have been sources of love, encouragement, and, increasingly, amazement at their development. They keep me grounded, modest, and enthusiastic for the future. I cannot wait to see the world they will help to build. Finally, I want to thank my wife, Kim. We are even better partners now than we were when we said our vows in the Friends Meeting House in Pennsylvania in 1995. I always learn from her patience and persistence and am inspired by how hard she works. I love you!

Contents

Chapter 1 Why Exposure?

1

Exposure Is Deceptively Simple  2 Therapist Concerns about Exposure  4 For Which Clients and Anxieties Is Exposure Appropriate? 4 What Is Exposure?  7 Goals of Exposure  9 The Focus of This Book  12

Chapter 2 Psychoeducation: Setting the Stage for Exposure

14

The Built-In Fear and Anxiety System  14 The Cognitive Triangle  17 Why Exposure and How Does It Work?  19 Setting Expectations  23 Ground Rules for Exposures  25

Chapter 3 The Fear Ladder, and Tips on Assessment and Monitoring in Exposure Treatment Assessing Key Exposure Targets  29 Building the Fear Ladder  40 A Few Words on Other Progress Measures  49 xi

28

xii Contents

Chapter 4 Conducting Exposures: The Basics

52

Preparation 53 The Actual Exposure  62 Debrief 67 Measuring Progress  71

Chapter 5 Exposure and Coping Skills

76

When to Use Skills Interventions (and When Probably Not To)  77 Skills Training Interventions  80

Chapter 6 Exposure for Specific Phobia

99

Description 99 The Pattern of the Phobia Fear Ladder  100 The Graduation Exposure  102 Cognitive Skills and Phobia  106

Chapter 7 Exposure for Social Anxiety

108

Description 108 Identifying Appropriate Social Exposure Targets for In-Session Exposure  109 Toward Clarity about Social Anxiety Drivers 120 Assessing and Addressing a Client’s Social Skills  123 Troubleshooting When Social Situations Go Awry  127

Chapter 8 Exposure for Separation Fears Description 135 Involving Caregivers  136 Assessing and Addressing Caregiver versus Client Fears  141 Caregiver Conflict  147 Child Irrational Fear versus Child Perceptiveness 154

135



Contents xiii

Chapter 9 Exposure for Worry

162

Description 162 Inclusion of Cognitive Strategies  163 Worry Triage  167 The Downward-Arrow Technique  170 Worry Exposure  172

Chapter 10 Exposure for Panic Disorder

176

Description 176 A Cautionary Statement  177 Some Definitions  177 Psychoeducation 177 Interoceptive Assessment  179 Interoceptive Exposure  185 In Vivo Exposure Related to Panic Disorder  191 Form 10.1.  Interoceptive Exposure Worksheet 196

References

199

Index

203

Purchasers of this book can download and print an enlarged version of Form 10.1 at www.guilford.com/southam-gerow2-forms for personal use or use with individual clients (see copyright page for details).

CHAPTER 1

Why Exposure?

D

ecades of treatment research, fueled in large part by federal funding, has identified what specific treatments work for which psychological problems that people experience. Although the bulk of this work has focused on adults, there has been considerable progress in understanding which treatments work best for children and adolescents. We now have a scientific literature with more than 1,040 randomized controlled trials (RCTs) comparing treatments for child and adolescent mental health problems, with hundreds more open trials and single case studies.1 Some problems have received more of our scientific efforts than others. It will surprise few readers to learn that almost 20% of RCTs have focused on treating disruptive behavior disorders in children. The problem in second place is anxiety, with 166 RCTs. The battle for third place is a close one, with autism spectrum disorders (99 RCTs) edging out attention-deficit/hyperactivity disorder (98); depression (87), substance abuse (70), and traumatic stress (66) round out the top six. Treating anxiety has been a major focus of treatment research for children and adolescents, outpacing studies of any problem except for disruptive behavior. As a result, we know quite a bit about treating anxiety in children. One big lesson is apparent: many studies support the idea that cognitive-behavioral therapy (CBT) is effective for treating anxiety. Setting the bar for success at either (1) two studies showing a treatment is superior to no treatment or (2) one study showing a treatment is superior to another active treatment, almost 90% of treatments that clear the bar are CBT. We have more than 75 RCTs that document the effectiveness of CBT for child anxiety. As a result, those in the field who work 1As

of November 2018.

1

2  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

with anxious children may find knowing CBT is a benefit. Thankfully, there have been a number of excellent articles and books published to spread the word on CBT to those who might benefit from it (e.g., Bunge, Mandil, Consoli, & Gomar, 2017; Chorpita, 2007; Kendall, 2012). I have chosen to focus on one behavioral element found in CBT programs: exposure. Let me take a few minutes to explain why. First, treatments are like recipes. A recipe includes a set of ingredients one needs to prepare a dish along with the instructions for how and when those ingredients are combined and prepared. Treatments are similar. They typically include specific strategies designed to be delivered in a particular order, at a particular dosage level, and in particular ways. With that cooking metaphor in mind, I turn to the ingredients of treatments that work for dealing with anxiety in children. Research by Bruce Chorpita and his colleagues reveals that over 87% of effective treatments include exposure (e.g., Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016). These data do not tell us that exposure is the key ingredient; however, the near ubiquity of the technique suggests that it is an important one. Furthermore, when we inspect these studies more carefully, by diagnosis, we find that exposure is included in recipes across all of the anxiety disorders, from specific phobias to generalized anxiety disorder to panic disorder, as well as obsessive–compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).

Exposure Is Deceptively Simple That the ingredient of exposure is so prominent in effective treatments might alone be reason enough to consider a book devoted to exposure. However, there is more to consider. First, exposure is a strategy that is deceptively simple. In a nutshell, the exposure intervention posits that if you are afraid of something and it is not dangerous, then approaching and engaging with that something will reduce your fear of it. The intervention represents the application of basic and fundamental scientific findings related to how humans and other animals develop fears. The deceptive part of the technique is that despite how simply one can describe it, exposure is one of the more difficult therapeutic interventions to implement. Why? Although subsequent chapters will make this clearer, let me offer a few preliminary points to keep in mind. First, the client who seeks treatment for a fear or anxiety has spent a lot of time being afraid and avoiding the feared stimuli. This means that there has been a history of that sneaky kind of learning you may remember from college



Why Exposure?  3

or graduate school: negative reinforcement. Avoidance leads to almost immediate anxiety reduction. As a result, our client has learned that avoidance works. Complicating this reality is the fact that the clients are children and adolescents. They do not usually consider themselves as having problematic levels of anxiety and many will have low motivation to participate in treatment. Furthermore, we can assume that the client has been able to convince most full-grown adults to permit them to avoid things they fear.2 Our client might be missing school, or sleeping with a parent, or not engaging in any social interactions, and more. All this occurs with the tacit permission of most if not all of the adults in their life. How are you, a therapist, going to change all of that? Further, exposure is a deceptively challenging intervention to deliver because it requires a variety of technical skills that are not obvious. For example, exposure requires repetition. It is not enough to expose a person to a feared situation one time. The one-off does not permit the sort of transformational change we are going for with exposure. To do exposure, clients have to experience the anxiety-provoking situation many times—so many times that they learn that the situation is not dangerous and that they can handle their anxiety in the situation. That repetition requires a therapist to have a high degree of self-discipline. Without repetition, the client only learns to white-knuckle through tough situations, using the grin-and-bear-it approach that will not likely lead to lasting behavioral changes. Exposure also requires an accurate assessment of what I call the drivers for the fear. By drivers, 3 I mean what it is about the particular situation or stimulus that creates the fear or anxiety. Understanding the underlying drivers will maximize the potency of the exposures, whereas failing to do so can mean choosing exposure tasks that are irrelevant to a client. Let’s take an example. Imagine we know that Leo4 is afraid to eat in his school lunchroom. Without knowing why he is afraid (i.e., what factors drive the fear), we could stumble our way, trial-and-error style, through exposures such as asking him to observe others eat lunch 2 A

note on language: In the book, I have given careful thought to pronoun use. In specific case examples, though they are all changed and amalgamated, I used the pronoun preferred by the individuals in the example. For all other situations in which pronoun use was needed, I used the “they/them/their” to indicate a genderneutral pronoun. 3 I adopt this term from the work of Scott Henggeler and colleagues in their books on multisystemic therapy (e.g., Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009). 4 All case material contained in this book is fictional, composite from multiple cases, or disguised.

4  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

in a lunchroom, eating lunch in simulated lunchrooms, and then eating in the client’s actual lunchroom. But what if Leo’s fears were related to the cleanliness of the tables? Or what if they were related to fearing social interactions in the lunchroom? You can easily see how a little more detail on why the client is afraid would lead to big shifts in what the exposure tasks looked like. Hopefully I have established that exposure is a major ingredient in most effective treatments for anxiety and that exposure is a tough intervention to deliver. But wait, there’s more!

Therapist Concerns about Exposure Despite its well-established potency across multiple decades of study, exposure raises many concerns about using it among many therapists. I have conducted dozens of trainings around the world on CBT since the mid-1990s. Sometimes in these trainings, I solicit a top-10 list of reasons that folks are wary about using exposure. The reasons often include concerns that exposure will be harmful to the client, that exposing the client to feared stimuli is not helpful, or that the client will refuse to participate. There are survey data (e.g., Becker, Zayfert, & Anderson, 2004; Deacon et al., 2013) that suggest therapist concerns about exposure are common and interfere with therapists’ willingness to learn and/or use the intervention, despite knowing that it has a strong evidence base. As a result, another reason to dedicate a book to exposure is to coax more child and adolescent therapists to consider using the technique despite their concerns. A book that focuses solely on exposure has a lot of boxes to check. It must provide clear instructions for how to plan and deliver exposure interventions. It must do so across a number of different problem types, diagnostic categories, and feared stimuli. It must also clarify for which problems exposure is appropriate and for which it is not appropriate. Finally, a book on exposure must anticipate and address concerns that the reader may bring to the book about the intervention. My goal for this book is to check all those boxes. I hope that, in the end, you will agree that I did.

For Which Clients and Anxieties Is Exposure Appropriate ? For whom is exposure appropriate? This book was written with children and adolescent clients in mind, roughly ages 5–18, and their families.



Why Exposure?  5

My experience with this population is extensive. I also have experience with adult populations, though I do not focus on those experiences in this book. There are some excellent books for using exposure with adults (e.g., Abramowitz, Deacon, & Whiteside, 2019; Barlow, 2014). Even limiting the focus to children and adolescents creates some practical challenges because there is great developmental variability from age 5 to age 18. As a result, throughout the book, I will attempt to make clear how one might adapt a particular strategy to fit the age of the child. For which fears and anxieties should one use exposure? There is a simple answer to this question: exposure is appropriate if a client is afraid of something and the following criteria are met: 1. It is not dangerous. AND 2. Approaching or engaging with the stimulus/situation may be any or all of the following: a. Necessary/required b. Helpful or beneficial AND/OR 3. The fear and/or avoidance of the stimulus/situation is interfering with optimal functioning. If criterion 1 is not met or either or both of criteria 2 and 3 are not met, then exposure is not likely to be the right approach. If criterion 1 and either or both of 2 and 3 are met, then game on. Let me provide a few examples. Riding an elevator to the 25th floor is not dangerous. Yes—sometimes elevators get stuck. But there are very few elevator-related fatalities. Recent data suggested that there are about 18 billion (that’s 12 zeros!) elevator trips annually in the United States; these trips result in fewer than 30 deaths annually. Your chances of winning the lottery are 1,000 times better. Elevator rides can also be necessary or helpful. I know: stairs are good for our health. However, 25 floors of them may not always be convenient and avoiding the elevator may lead to being late to an appointment as well as missing out on lots of interesting opportunities only found on high floors of buildings. Thus, fear of elevators is a legitimate focus for exposure. Consider a dramatic alternative: being shot by a firearm. Being shot (or even shot at) creates a lot of justifiable fear. Being shot is dangerous. In some neighborhoods and schools there is the possibility of gunfire. For almost all people, being shot is something they strive to avoid, and

6  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

for good reason. A similar example would be the experience of childhood physical abuse. This is also a true danger situation. Neither of these life examples are appropriate targets for exposure therapy. Instead, I would recommend safety planning, self-defense training, problem solving, and crisis management as possibly useful interventions. Let’s pause a moment, though, and consider a person who was shot or abused in the past. We know that those acts (being shot or abused) do not meet our criteria as a legitimate focus for exposure. However, what about the memory of being shot or abused? That is a more perplexing question and one that we regularly encounter in clinical practice. Let’s walk through the criteria. 1. Are the memories dangerous? They are definitely painful, distressing, and upsetting. Few of us look forward to remembering such events and many of us will work hard to avoid such memories. However, is the memory itself dangerous? The answer is no. The memory itself will hurt emotionally but cannot harm you like the actual event did. 2. Is remembering the memory necessary and/or will it be helpful? The answer here is probably yes. Many of us get stuck avoiding thinking about these painful memories and cannot move forward as a result. 3. Finally, avoiding the memory often creates problems and interference, especially when some of the memories about the event are distorted. For example, a person may avoid many situations in life to reduce the chance of thinking about or recalling the traumatic event, thereby missing out on important opportunities. Checking all three criteria as yes, we can conclude that memories of having been the victim of gun violence or of child abuse are good targets for exposure. Most examples are not quite this obvious. Take social interactions. Sometimes, social interactions are painful experiences. People can be real jerks sometimes. Rarely, these interactions can turn violent. For the most part, though, social interactions are not dangerous, thereby meeting our first criterion. Although some clients will disagree, social interactions also nearly always meet both criterion 2 and criterion 3. Often with social fears, the key is to ascertain the true danger posed by specific individuals or social situations. Most are not dangerous and exposure will be helpful. Some few, though, are not good candidates



Why Exposure?  7

for exposure. I spend a bit more time on this theme in the chapter on social anxiety. An even less obvious example is spiders. Many people are afraid of spiders. Indeed, there is good reason to be afraid of a very small number of spiders, as a few are venomous and dangerous to humans. However, for the most part, spiders rarely pose a true danger to humans. As I like to joke with my clients and students, rare is the spider who hunts humans for food. More realistic would be a spider fearing humans, as we can easily and even accidentally kill them with one step. However, as to criteria 2 and 3, there is a lot of potential for variability. Some of us may encounter spiders regularly, through being outside frequently for work or recreation or living in climates with a lot of spiders and other insects that cohabitate with us, despite our best efforts to keep a pestfree home. A recent census study in North Carolina found that the average urban and suburban home has between 24–128 spiders and other arthropods living in it (Bertone et al., 2016). Some of us rarely encounter spiders. Or, more likely, we may share space with spiders and not notice them. As a result, a fear of spiders is a reasonable target for exposure therapy, but for many people, the lack of impairment associated with the fear may be so negligible as to make exposure or any treatment a low priority. It is possible many of us could cultivate a better relationship with our friends the spiders. However, for some of us with strong fears, such work may yield few benefits and remove no problems, leading one to conclude: Why bother treating that fear? The main takeaway here is that exposure is a potent tool for treating fears of nondangerous stimuli and situations for clients whose fears are interfering with their optimal functioning. Spending time with those stimuli and in those situations will lead to a reduction of fear and, if the engagement is persistent, a corrective learning experience. However, if the situation or stimulus is dangerous, exposure is not the preferred treatment. Instead, consider other options including safety planning, crisis management, and problem solving.

What Is Exposure ? Mary Cover Jones’s case of Peter, published in 1924, is one of the first documented examples of behavior therapy being used to treat fears. Almost 3-year-old Peter had developed a fear of small animals including rats and rabbits. To combat the fear, Cover Jones engaged in a process of what she referred to as unconditioning, in which she presented

8  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

the feared stimulus (she used a rabbit) along with a pleasant stimulus (she used food). Cover Jones opined that by pairing the pleasant stimulus with the feared stimulus, over time, the fear would decrease. Her approach was a gradual one. At first, the rabbit was quite distant from young Peter as he was fed a food he liked. Over time, the rabbit was brought closer and closer. By the end of their work together, Peter was fondling the rabbit closely. Cover Jones’s approach included some of the key elements that we now associate with exposure therapy. First, she targeted a fear that was irrational and a stimulus that was not dangerous. Second, she exposed the client directly to the feared stimulus. Third, her approach to exposure was gradual and used a fear ladder or hierarchy of sorts. In short, Mary Cover Jones can be credited for devising some of the most important underlying intellectual property for the technology of exposure therapy. She also included a procedure that can be considered a forerunner to that used in systematic desensitization (popularized by Joseph Wolpe, 1958), whereby a feared stimulus is paired with a pleasant and/or relaxing stimulus. Though this procedure was an important one in the history of exposure, the inclusion of the paired pleasant/relaxing stimulus is no longer used by most therapists who do exposure. Around the time of CBT’s first ascendance, Edna Foa and Michael Kozak (1986) published an important paper that provided a robust rationale for the centrality of activating what they called the “fear structure” for treatment of anxiety to be effective. Drawing on Peter Lang’s (e.g., 1977) bioinformational theory, their concept of fear structure referred to the biological, cognitive, and behavioral complexity of our fear-related memory. Specifically, they noted that the fear structure was composed of three components: (1) data about the stimulus or situation, (2) data about the person’s reactions (e.g., actions, thoughts, feelings) to the stimulus at the time of fear acquisition, and (3) the person’s interpretation of these two sets of data. They posited that for the fear to be adequately treated, the fear structure in toto must be activated and processed, leading to new learning about the fear stimulus. They provided examples of how failures to engage in this exposure and deep-processing approach lead to less-than-adequate treatment responses. There is one more theoretical point to consider. In the last decade of the 20th century and into the 21st century, research and theory began to suggest that clients with anxiety problems not only feared specific stimuli but the experience of fear itself. This phenomenon sometimes



Why Exposure?  9

generalized to emotional experiences more broadly and was referred to as experiential avoidance (i.e., the avoidance of unpleasant internal experiences), a phrase coined by Steve Hayes and colleagues (e.g., Hayes, Strosahl, & Wilson, 2012). Subsequently, theoretical and empirical work made exposure to the experience of anxiety itself, rather than to specific stimuli alone, an important goal. In other words, there was an emerging understanding that the client’s fundamental relationship with their own anxiety had to change such that they learned that they could handle the anxious feelings, even when extreme. To accomplish this goal, exposure approaches emphasized the importance of the client experiencing their anxiety without distraction or avoidance. Taken together, one can see how all of these advances in our understanding of how anxiety problems develop and change led to exposure as a preferred treatment approach. That does not mean that relaxation and other coping strategies, common techniques found in systematic desensitization and many CBT programs, are not considered legitimate components of effective treatment. I will cover these strategies later in the book. The important takeaway lesson here is that exposure alone— without paired relaxation or other coping strategies—has come to be viewed as a potent (and the most potent by some) ingredient in treatment for anxiety.

Goals of Exposure One main goal of exposure therapy is for the client to approach and engage with previously feared stimuli with reduced or even no anxiety or fear. This will be apparent when the client’s fear of the stimulus or stimuli is reduced across most of the ways that the stimulus is manifested. The client will be doing things they have not done in a long time, if ever. And doing them with little or no anxiety. The client and their family will report notable functional gains. These gains are one goal of exposure therapy. And they are an important one. Another goal of exposure is to help the client see that the process of achieving mastery over one set of feared stimuli can be abstracted as a tool that they use as they move forward and encounter new fears and anxieties. In other words, the goal of exposure is not just to climb one or two fear ladders that the client faces now. It is for the client to learn how to build and climb their own fear ladders so that future feared situations become ones that are mastered. My colleague Bruce Chorpita (2007) has

10  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

coined a great phrase for this goal: the exposure lifestyle. If we are afraid of things in our lives and they are not dangerous and could even be good for us, then exposing ourselves to them is the way forward. The third goal is inspired by a talk I once heard from one of the world’s most well-known anxiety treatment scientists, David Barlow. Barlow spoke of exposure being not just as an approach used for addressing specific feared stimuli but rather as an approach that could help a person grapple with and develop a better relationship with their own anxiety. In other words, exposure helps us to learn not just about the stimuli that we fear but with the stimulus of fear itself. Our own internal experience of fear is something that we learn to master. These three goals are the overarching aims of exposure treatment. There is an additional goal that warrants mention. Learning involves the acquisition of new behaviors whether those behaviors are overt or covert. Therefore, fears are acquired through learning and must be overcome through more and different learning. Learning occurs through a repeated pattern of thoughts, feelings, and behaviors. Through each repetition of the pattern, a particular learned behavior is strengthened. When we are dealing with fears and anxieties, we are often confronted with uprooting long-held patterns of thought, feeling, and action. And not just thought, feeling, and action of one individual but often of the whole system in the family. This relates to the concept of habituation and its two types: within-trial and between-trial habituation.

Habituation First, let’s start with the word habituation. It is a term derived from research on sensation and perception, wherein some stimuli become invisible to us over time if they do not have informational value, like the sound of an air conditioning system in an office or the sight of a small stain on the carpet after you have seen it dozens of times. They just disappear from your awareness because paying attention to them does not help you. The same basic notion applies to feared stimuli in exposure. Our goal is for the client to learn that the stimulus is not dangerous, that the anxiety experienced is out of proportion to it. The goal is that the client habituates to the stimulus and to the fear it produces. We accomplish this through within-trial and across-trial habituation. A trial of exposure involves the presentation of the stimulus a single time. For example, 13-year-old Angel, who is socially anxious, says “Hello” to my receptionist once. That is one trial. By within trial, I mean



Why Exposure?  11

within that single event. To understand whether the client is experiencing within-trial habituation, I must measure their anxiety level at the start and then again at the end of that single event. Within-trial habituation occurs when the anxiety at the start of the event is higher than the anxiety at the end of the event. In short, the client’s anxiety level has decreased during the event. And just like that, they have achieved within-trial habituation. With within-trial habituation, the client learns that if they approach and engage with the stimulus, their anxiety level will decrease eventually. Figure 1.1 depicts this situation across four trials. You can see that in the first two trials, the ratings were the same before and after, with a mild reduction. In trial 3, you can see the starting anxiety rating stayed the same but the reduction was more extreme. In trial 4, the starting and ending points were both lower. The reduction in the initial rating in trial 4 is excellent news and is a good time to transition to the other kind of habituation. With across-trial (or between-trial) habituation, the focus is the experience of anxiety at the beginning of each trial. That is, from trial 1 to trial 2 did the initial anxiety rating decrease? How about from trial 1 to trial 4? Not only does anxiety go down if the client approaches and engages with the stimulus, anxiety gets lower the more the client does it. The more we do something we are afraid of, the less anxious we will be when we go to do it the next time. In short, it keeps getting easier. Figure 1.2 depicts across-trial habituation using the data from our first four trials in Figure 1.1 and adding the next two trials. Here, the dotted trend line represents across-trial habituation. Another important thing to note in the data here will be a theme throughout the book— namely, that it takes time to see habituation. It is imperative not to give up if exposure does not seem to work the first few times you try it. After Trial 1 6 4

5 3

2 0

Trial 2 6

Ini�al Anxiety

End Anxiety

4

5 3

2 0

Trial 3 6

Ini�al Anxiety

End Anxiety

4

5 2

2 0

Trial 4 6

Ini�al Anxiety

End Anxiety

4 2 0

3 1

Ini�al Anxiety

FIGURE 1.1.  Within-trial habituation across four trials.

End Anxiety

12  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS 7 6

Anxiety

5 4 3 2 1 0

1

2

3

4

5

6

Trials

FIGURE 1.2.  Across-trial habituation across six trials.

three trials, one might have been tempted to abandon ship. However, only three trials later: what a difference!

The Focus of This Book I trust that this chapter not only has you convinced that exposure warrants a standalone book, but also has persuaded you to read on. Let’s turn now to what to expect in the subsequent chapters. Chapter 2 introduces you to how to present some basic psychoeducational concepts that underlie exposure to clients. Chapter 3 focuses on the central role of assessment and monitoring in exposure therapy. Here, the emphasis is on building the fear ladder, an essential preparatory and ongoing part of exposure treatment, and on monitoring progress in treatment. The job of Chapter 4 is a monumental one. Here, you will find the basics of exposure—that is, a practical guide to how you will do exposure with a client, from start to finish. The basics covered here are expansive and the chapter is one of the longest in the book—and with good reason. There is a lot to know about exposure. Chapter 5 takes a quick break from exposure and focuses on how to integrate coping skills training into exposure work. These skills include relaxation, cognitive, and problem-solving skills. The chapter is not meant to provide full coverage of these skills—there are whole volumes dedicated to them. Instead, the chapter provides a taste of each, including how they can be used while doing exposure and how they can be used as a way to cope and take a brief break from exposure.



Why Exposure?  13

The final five chapters focus on five different anxiety disorder categories, providing more specific guidance and examples for how exposure is used for phobias, separation anxiety, social anxiety, worries, and panic. Though some of the principles presented in Chapter 4 are relevant for PTSD and OCD, I do not include chapters on these two subjects and refer the reader now to some excellent books on those topics for more detailed information (e.g., PTSD: Cohen, Mannarino, & Deblinger, 2012; OCD: March & Mulle, 1998; Fleshner & Piacentini, 2017).

CHAPTER 2

Psychoeducation Setting the Stage for Exposure

One of my favorite aspects of CBT as a treatment approach is its trans-

parency; the therapist is open with the client and caregiver about why they are intervening in the way they are. There is not anything secretive or mysterious about the intervention. A good CBT therapist teaches all of the procedures they know to the client and caregiver such that they no longer need a therapist. A common first step is to provide in-depth psychoeducation. The psychoeducation checklist for exposure includes (1) explaining the fear and anxiety system, the cognitive triad, and how exposure works; (2) setting client and family expectations; and (3) establishing the ground rules for clients and families, and clarifying your role as therapist. Let’s review each of these steps in turn.

The Built-In Fear and Anxiety System A key first point is to explain the important role anxiety plays in our lives. Anxiety and fear are normal and healthy responses to experiences in our day-to-day existence. From an evolutionary perspective, anxiety is related to our survival as a species. Fear motivates us to fight or flee present and imminent dangers to our physical bodies. This fight-orflight system is built into our autonomic nervous system, specifically its sympathetic nervous system (SNS) branch. We all should be grateful for the SNS; it is truly a lifesaver. No question it saved our forebears many times. And most of us can remember times when the quick and 14



Psychoeducation 15

unconscious action of the SNS allowed us to avoid a sudden danger, like a car that suddenly swerved toward us, or to instinctively catch a child as they fall off a swing. One other important fact about the SNS is that when it is truly activated in a fight-or-flight way (and not just revving up), you cannot do anything to stop it. The system operates like the release of a wound-up toy car; it goes zooming around the table until it runs down. Once fight or flight is activated, the flow of adrenaline and other hormones through the body must run their course naturally, a process that can take 5 to 15 minutes (or longer). Anxiety also motivates us to anticipate and plan for threats by leveraging the potent power of our multifaceted brains. For example, our limbic system assists us by locking down memories of frightening experiences, and helping us to learn from them. Furthermore, our cerebral cortex interacts with our limbic system to leverage those memories to identify ways to improve our chances of coping and to work toward preventing or eliminating threats. Over time, as we developed sophistication as a species, the actual and credible threats to our bodily survival have been greatly reduced for many people. The consequences of a strong, built-in fear and anxiety system are each relevant to using exposure interventions. First, the built-in system works well at keeping us alive and is, as a result, reinforced. That is, because our fears and anxieties can sometimes lead us to take actions that avoid a real danger and/or reduce our risk for harm, we learn that the system has tangible benefits. Second, the system can be overly sensitive to danger. What clients need to understand is that a primary reason for anxiety disorders is the system’s overestimation of the threat posed by everyday situations such as social interactions or daily hassles. Normal, stressful experiences can sometimes be interpreted as life-or-death threats, resulting in strong fight-or-flight reactions. One challenge that results is that from inside the nervous system, the fight-or-flight reaction that results from a real danger is not distinguishable from a fight-or-flight reaction that results from a stressful experience that is not a real danger. Let’s listen in on how one therapist explained this idea to a 12-year-old client named Max, who had social anxiety and lots of worries. Therapist: Anxiety is a lot like an alarm system. Does your family have a car with a car alarm? M ax: Yeah. Therapist: What is the alarm for? M ax: Um, I guess to make sure someone doesn’t steal the car.

16  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

Therapist: Right. We would call that a real danger. The alarm is there to stop someone from stealing the car. Have you ever heard the alarm go off before? M ax: Yes. A few times. Therapist: Loud, right? M ax: Really loud. Therapist: Like . . . (Makes an alarm sound.) M ax: Yeah, but louder. (Makes an alarm sound.) Therapist: The last time you heard the alarm, was someone stealing the car? M ax: No. It was because my sister tried to open the door but it was locked. She kept pulling on it and bang. Alarm. Therapist: I bet she was freaked out! What about the other times? Any time it went off when someone was trying to steal it? M ax: No. Once it was because someone had bumped the car in a parking lot. Therapist: Hmm. Those are false alarms, right? They happen. I have a couple of questions that might be kinda hard to know. So just your best guesses. First, what do you think the alarm sounds like if someone was trying to steal it? How would the sound be different? M ax: Um, I think it would sound the same. Therapist: So how do you know whether it is a real alarm or a false one? M ax: I don’t know. I guess you have to check. Therapist: Right. We have to get information. To check it out. It might be a problem. It might not. Sometimes the alarm makes mistakes. Our anxiety system in our body can be like that. Sometimes it gets us really worked up and there is not a real danger. Another question for you—when the car alarm is a false one, how easy is it to turn it off? M ax: Um, super easy. If you have the keys, you just have to push the button. Beep. And it stops. Therapist: You know a lot about your car alarm! M ax: I love cars! I can’t wait to be able to drive. Therapist: Cool—it is fun! So, a false car alarm is easy to turn off. A false anxiety alarm, though. That we can not turn off too

Psychoeducation

17

easily. It takes a few minutes for it to ease off. We will talk some about how to help with doing that. But the important things I want you to know for now is that we have an alarm system, sometimes it turns on when there is no real danger, and the alarm does not just turn off once we know everything is okay.

thE coGnItIvE trIanGlE Once you have established how our potent built-in fear system operates, your next point is to introduce the idea that what we think influences what we feel and do (and vice versa). Thanks to our well-developed cerebra, we are able to anticipate threats and danger. With our thoughts, we can imagine and forecast when and where danger will strike, a blessing that is a double-edged sword, especially when it comes to anxiety. Just as we can use our thoughts to help us achieve many things, we can also use our thoughts to imagine many terrible futures. Of course, here I am introducing the well-known cognitive-behavioral model. Most readers are likely familiar with the model; as result, let’s just take a peek at how a therapist might introduce it to Max in the context of preparing for exposure. TherapisT: Now that you get the alarm idea, I want to talk about some ways that anxiety, and that alarm system, can be changed. To do that, I want to show you this picture. (Shows the cognitive triangle, as in Figure 2.1). Tell me what you think this might mean? M ax: I don’t know.

Thoughts

Actions

Feelings FIGURE 2.1. The cognitive triangle.

18  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

Therapist: Let’s break it down together. The words—what do they mean? (Points at “Thoughts.”) What is that one? M ax: That is like stuff in your head. What you think. Therapist: Bingo! Right. And how about this one? (Points at “Actions.”) M ax: That is what you do. Therapist: Right! And last? M ax: How you feel. Therapist: Cool—good. So what do the arrows mean? M ax: I guess they like point to the other one. Like they lead to it? Therapist: Yep. We could say they change each other. Now a question: According to the picture, which one is most important? M ax: Um, I guess “Thoughts”—it’s at the top? Therapist: True—it is at the top. But what if I shifted the picture like this. (Turns the picture so “Actions” is at the top.) Does that still look like “Thoughts” is most important? M ax: No. Now “Actions” is? Therapist: And now? (Shifts the picture so “Feelings” is at top.) M ax: OK—I guess none of them is most important? Therapist: Right—it is like a circle—but it looks like a triangle. A circangle? Bad joke—anyway, where do things start? Does the picture tell us? M ax: Not really. I mean, a circle does not have a start really. Therapist: Great. That is gonna be important for us. These three things here are changing each other all the time. And we cannot tell where it all started really. It doesn’t matter. We can still help ourselves if we are feeling really anxious, because we can change one or more of these things. Let’s take thoughts as an example. Imagine I was feeling anxious because I had a big test coming up. Can you picture that? M ax: Ugh, yes. I hate tests. Therapist: Me too. So let’s say I have a big test coming. Math. And I am feeling anxious already. And, let’s say I think, “This test is gonna be really hard; I bet I fail.” If I had that thought, how would that change my feelings, do you think? M ax: Make you more nervous, I bet.



Psychoeducation 19

Therapist: Yep. I bet you are right. So I start to feel more nervous. But what if I thought, “I studied hard for that test.” Or what if I did study, like took an action to study. What might those things do to my feelings here (pointing at picture)? M ax: Maybe make your nerves go down a little. Therapist: Right! You are really doing great at understanding this. With the second basic rationale for exposure locked down, the next step is to provide a quick and basic explanation of exposure itself and why it makes sense for treating anxiety.

Why Exposure and How Does It Work ? On the face of it, exposure therapy makes complete sense. Of course you should face your fears! At the same time, exposure can be an incredibly hard sell to clients. It is obvious that people do not want to do things they are afraid to do. How then are you going to convince them, especially when clients have been able to convince themselves and others in their lives that they can live by avoidance alone? Facing your fears can be broken down into three separate points that begin to sell exposure to clients: (1) avoidance strengthens and perpetuates fear, (2) approaching and engaging with feared stimuli reduces fear, and (3) repeated approach reduces fear and fosters new learning.

Avoidance Makes Things Worse Avoidance is a linchpin in problematic anxiety and is a classic example of negative reinforcement—the removal of an unpleasant experience reinforces the behavior that preceded it. A person experiences anxiety and its unpleasant physiological manifestations—pounding heart, roiling stomach, and a racing mind. Who likes these feelings? Any behavior that leads to a decrease or removal of the anxiety experience will be reinforced. Avoidance is an “excellent” anxiety management strategy, leading to an almost immediate cessation of the anxiety experienced. If a teenager is afraid to talk to a particular cute person at a party and they spend their time at the buffet table or even leave the party instead of seeking that person out, their anxiety immediately decreases. That immediate decrease reinforces the choice to avoid. This recipe is a key reason why anxiety has so many disorders associated with it. We are understandably using a successful anxiety management strategy that has

20  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

long-term negative consequences that are not immediately apparent. The main problematic long-term consequence is that we do not give ourselves the opportunity to have a potentially corrective learning experience with the feared stimulus. Instead, we learn that avoidance works. Understanding how avoidance is negatively reinforced allows you to lay out the rationale to the client and their caregiver for exposure as an intervention for the concerns they bring to the clinic. You must make the point that being afraid of something and avoiding it becomes a self-sustaining loop. The client and caregiver must understand that each time someone avoids the thing they fear, the fear is enhanced and the difficulty they will experience in approaching the thing will increase. Let’s see how Max’s therapist approached this. Therapist: Now I have to tell you about something you probably won’t learn until you get to college. You ready for some college knowledge? M ax: Um, OK. Therapist: First, I want you to tell me something you really like. Something awesome. M ax: Like maybe a video game? Therapist: Perfect. The best video game. Imagine you could play that game. All you had to do was to grab the controller to play. It is already running. M ax: Cool! Therapist: Yeah—cool. But . . . dunh dunh dunh . . . when you grab the controller, it makes a really loud and terrible noise. Like a severe and painful siren. Once you put the controller down, the sound goes away. Whew! The silence is really nice after that terrible sound. It feels a lot better. Things are a bit tricky now. To play that cool game, we have to endure that sound. This is a lot like with anxiety. There is a lot of fun stuff to do but anxiety is like a loud siren. If we move away from that stuff that makes the anxiety siren go off, we feel better but we don’t get to do the fun stuff. In the video game example, what do you think you would do? M ax: Can I turn off the siren sound? Therapist: How would you try to do that?



Psychoeducation 21

M ax: Can I get another controller or something? Therapist: No. Only that one controller will work. M ax: I don’t know. Therapist: Here is the college knowledge part. What if I told you that if you held onto the controller long enough, the siren would stop and that you could play? M ax: Really? Therapist: Yes. Really. The siren will stop eventually. You just have to hang on a little bit. Anxiety works the same way. And we will talk about that more later. A big thing to remember here is that it can be tempting to give up and move away from the siren. It is like a little trap we all fall into. But we are going to learn in our meetings that if we hang on and wait, the siren will stop and we will get to play. It will be tough at first, because it is a habit to escape. And the siren is awful. But with practice, it gets easier. And I will be here with you to help you the whole time.

Approach Is the Answer When the client grasps the idea that avoidance strengthens anxiety, you shift to help them to understand that the path forward is through approach and engagement with the feared stimuli/situation. There are several anticipated outcomes of approach. First, the client can learn whether or not their anticipated fears about the situation, person, or object, are true. That is, approach tests the client’s own hypothesis that there is a threat. Hence the caveat that exposure is only appropriate for false alarms. Exposure as presented in this book is not about building endurance to dangers. Instead, the first goal is to demonstrate to the client that their guess about the danger of some stimulus was inaccurate. Second, and more importantly, approach tests another usually unstated hypothesis: that the client is not capable of handling the anxiety or fear experienced. This idea has as its operating principle the same sentiment that President Franklin Delano Roosevelt offered in dire times for the United States: “There is nothing to fear but fear itself.” With exposure, a primary learning task concerns improving our relationship with and experience of anxiety. The client learns that they can handle their fears and anxiety even when they are strong and feel unmanageable. As long as the situation they fear is not dangerous, they can learn how to approach it successfully and to manage their feelings about it.

22  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

Ideally, our clients will learn two lessons: (1) their anticipation about the feared stimulus has some inaccuracies and (2) they can handle their anxiety about the stimulus. The point here is not “If it doesn’t kill you, it will make you stronger.” Remember that the focus of exposure is on nondangerous stimuli. Instead, the point is that spending time actively engaged with situations or stimuli will help a person learn whether or not they are a true threat. By remaining engaged with a stimulus or situation that is truly nonthreatening, clients learn of its lack of danger.

Frequent, Repeated Approach Works Best The final point is that repeated and frequent approach works best. One-time exposures are rarely effective. By frequently and repeatedly approaching and engaging, the client can instill the necessary learning. The commonsense way to understand this point is to reflect that we can almost always do something scary one time. By doing an exposure many times, clients are preparing themselves to become so accustomed to their presumed fear that they can face it more bravely in the future. To accomplish this task, they need a path that is different from the hold-mybreath, I-can-handle-anything-once approach. That means the frequent, repeated practice strategy. Why does the strategy of frequent and repeated engagement with the stimulus work? Again, the answer is related to learning. Through frequent and repeated approach, clients learn each time about the stimulus or situation. They add to their knowledge base about its danger to them. And, over time, clients learn that it is not in fact dangerous. And sometimes, clients learn that the situation or stimulus can be useful and even pleasurable. As an example, imagine a person with social fears such as not wanting to meet or talk to people whom they have never met before. Through repeated exposure, they have the opportunity to have many rewarding social experiences and learn new and different ways to interact with others. Even if some of the interactions are less than great, the more they engage in them, the more positive ones will accrue. And the more they do, the more they learn. Along the way, they develop their own social competency, thereby increasing their chances of future social successes. As clients approach and engage with nondangerous things that they fear, they also develop a sense of their own competency. They learn that they can handle stress and/or anxiety and/or fear. They learn that they are not the fearful person they thought they were; each is a person who can cope!



Psychoeducation 23

Bonus: Flooding Works; So Does Gradual Exposure There is a bonus point that could be made for some clients, typically clients who are particularly savvy with regard to exposure therapy or those who had some fears and misconceptions about how exposure therapy works. This last bonus point concerns the relative effectiveness of flooding versus gradual exposure. Let’s take a step back to understand these concepts. With flooding, the client is exposed to their worst fear almost immediately in treatment until they experience anxiety reduction. Most recently, this approach was operationalized in what is referred to as “one-session treatment,” though the concept of flooding is as old as the exposure intervention itself. It is important to understand that flooding does indeed work. Studies by the research teams of Öst (e.g., 1989) in Sweden and Ollendick in the United States have indicated that this approach is effective (e.g., Ollendick & Davis, 2013). However, many clients will not sign on for an approach like flooding. The good news is that gradual exposure—using a fear ladder to slowly and over time expose the client to more and more fear-inducing stimuli—is also an effective approach. In fact, gradual exposure has been tested more often than the flooding approach. Both are considered effective but one need not use flooding to achieve treatment goals. Making this point with clients can accomplish two separate things. First, it can offer to the client the opportunity to participate in a flooding approach. Some clients, particularly those who need to deal with immediate issues that are impeded by their fears, may be motivated enough to agree to a flooding approach. In our clinic, we sometimes have clients with time-critical deadlines that necessitate a flooding approach, like a pending plane trip for a client with a fear of flying or a major class presentation for a client with social performance fears. For most clients, you can reassure them that although you will be using exposure, you can use a gradual approach.

Setting Expectations You want to set expectations for the sessions and the overall course of treatment. Those expectations are derived from the client’s goals and are based on what the exposure approach can accomplish. That is, you need to clarify for clients and their families the extent to which their goals can be accomplished using exposure. In doing so, you elucidate the expected changes to be achieved through exposure. You also can make clear which changes will not be likely to occur.

24  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

A few examples will help clarify these ideas. I once met with an 11-year-old client, Jennifer, who had a younger sister who was 9. Jennifer was introverted and socially anxious. She had a few good friends but had trouble making and maintaining new friendships due to her anxiety about interacting with others socially. Her sister, on the other hand, was a social butterfly. The family understood and appreciated the differences between the two siblings. However, because the mother had a childhood experience similar to Jennifer’s, she hoped that treatment would lead to Jennifer becoming more like her sister; to the mother, life looked better as a social butterfly. In this case, I needed to make clear to the mother that although Jennifer would be much more comfortable in social situations after treatment, she probably would not be the social butterfly that her sister was. Jennifer was socially anxious also because of her temperamental style, which would likely limit how extroverted she eventually would become. I assured the family that Jennifer would learn to be much more comfortable in social situations and to be much more socially flexible. However, I also worked to reduce the family’s desire for Jennifer to become a different person. In short, when setting expectations for exposure treatment, we need to be clear that exposure can reduce anxiety and help clients become more comfortable in anxiety-provoking situations. However, it cannot change clients’ basic nature. That is, exposure therapy is not a personality transformation therapy. Instead, exposure therapy allows the client to be a less fearful and more approach-oriented version of whoever they were already. Let’s consider another example. This client, Whitney, was a 13-yearold girl who was an incredibly adept worrier. She could worry herself in circles about almost any topic. Her worries were greatly distressing for her and she experienced many physiological symptoms as a result of them. She also was not able to derive as much pleasure out of life as others her age because she was so quick to find ways to worry about things. The constant need to reassure Whitney that her worries were unfounded was both frustrating and exhausting to her parents. Whitney, like many clients who worry, wanted to completely eliminate all worrying. I sometimes refer to this as a worry-dectomy. As much as I wish that I could perform such a procedure (there would be quite a market), I needed to clarify that all I would be able to do is change the relationship she had with her worries—not eliminate them entirely. I told her that I could reduce the amount of time you spend worrying and reduce the amount of distress you experience about the worries. I can help you to short-circuit the worries more quickly. You will become a better worrier. However,



Psychoeducation 25

you will still worry sometimes. And, indeed, there may be times when the worrying becomes intense again. Especially during times of stress.

Ground Rules for Exposures The next step is to set some ground rules by clarifying what exposures entail and the rules for all those involved. Let’s start with ground rules for the client.

Client Ground Rules First, the client needs to do their best, which first means that they are encouraged to engage in the activities that the therapist suggests. They need not do them perfectly. Clients should be warned that they may be frightened at times, but that experience is to be expected. Another important rule for clients is to establish agreed-upon anchors for their ratings. Let’s see how Max and this therapist talked this one over. Therapist: That rating scale we are going to use is really important, so we need to have an agreement about it. The ratings are the way we know how things are going. I want to review the rating scale again to be sure we both are on the same page. How does that sound? M ax: OK. Therapist: We used this scale. (Shows a picture of a thermometer with 0 at the bottom, 5 in the middle, and 10 at the top; points at the 0.) Here, this zero means . . . M ax: No anxiety. Therapist: When does that happen? M ax: I don’t know, like maybe I am playing a game with my friend? And it’s a weekend. And it’s fun Therapist: Sounds great! What about here at a 3. M ax: That is like a little bit of nerves. Like when I am worrying a little bit about something, like maybe my mom might get sick. Therapist: Hmm. OK. How do you know it is a 3? Like what would your body be doing at a 3?

26  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

M ax: I don’t know. I guess a little bit of a fast heart beat. Not too much though for a 3. Therapist: OK—that makes sense. (Reviews other ratings.) Therapist: Now here comes the hard part. When we start to do the exercises I told you about—we call them practice sessions. I want you to be honest about your ratings. If it is a 7, tell me. If it is really a 3, tell me. Think of it like we are on a team playing a video game together. And your ratings help me to work best with you. If your ratings are true, then we win together. If they are not true, then we have trouble. Let’s start right now. I know some kids I work with get nervous just thinking about doing the practices. What is your rating talking about doing them? Right now? M ax: Um, I guess like a 4 or 5. Therapist: How do you know? M ax: My heart is going a bit. Therapist: That makes sense. I don’t know if you can tell, but you also look a little tense in your shoulders. Like here. (Taps his own shoulders and hikes them up to show tension.) I do that too. If I am at a 7, my shoulders get all the way up here to my ears like a turtle.

Family Ground Rules For the participating family, there are also ground rules. Although the involvement of most families is relatively limited in the beginning, once exposures start, many families become a lot more involved. The first rule is to encourage parents to do exposures at home. There are 168 hours in a week. If only one of those is spent doing exposure, progress will proceed slowly. If work happens at home, too, then progress will move more quickly. Consider this example. José is a selectively mute 7-year-old and only speaks to members of the family. As exposure proceeds, the client begins to talk somewhat more comfortably with the therapist and with others to whom the therapist exposes him. As treatment progressed, the family became more actively involved in the process. They were trained in how to conduct exposures with José and then encouraged to arrange a number of outside-of-session exposure tasks. For example, when at a restaurant, the family encouraged and eventually required José to order for himself. Similarly, the family sought opportunities for the client to



Psychoeducation 27

practice his speaking to strangers. They were at Lowe’s and needed to find out where they kept the filters for the air conditioner. They asked José to do it. They needed someone to answer the door when the delivery person arrives. José was on the job. They wanted some information from the soccer coach about the next practice. Guess who got tapped for that one: José!

Therapist Ground Rules Finally, there are ground rules for the therapist. These rules also help you to clarify your role to the client and their parents. Therapists will need to build trust with the client. In exposure treatment, you can build trust in a few different ways. You collaborate with the client in building goals; you listen to the client’s concerns carefully and incorporate them into the focus of treatment. In addition, you follow through on what you say you would do. If you promise to save time for a game at the end of session, you do that. If you say that the client will only do five trials of a particular exposure, you stop after five. You must be a person of your word. You, as therapist, will never ask the client to do something they are not able to do. You will also admit when you have made a mistake by selecting a task that is too challenging. Those things said, you are also required to push the client out of their comfort zone and into the learning zone. That is, your role will be to keep the client safe and also set high expectations. In this way, the therapist’s role is at times quite similar to that of a coach or mentor, someone who brings out the best in a person through a balance of encouragement, feedback, and pushing. The role for the therapist in exposure is to help clients develop a new skill. When clients learn something new, they will not necessarily be confident or competent in that skill. Thus, you calibrate your encouragement and feedback throughout treatment. In the beginning, you celebrate small victories and build those up to help strengthen the client’s confidence and competence. As things progress, you continuously and gently move the goalposts forward so that the client is striving for more. As they get better, the tasks get harder. Yet the tasks are always doable. With these psychoeducational points learned, you are ready to move on to building a fear ladder.

CHAPTER 3

The Fear Ladder, and Tips on Assessment and Monitoring in Exposure Treatment

Assessment and monitoring are the bedrock of clinical work, the

unsung heroes of our efforts with clients. This chapter focuses on these two mission-critical elements of clinical practice and how they are used in exposure treatment. The clinician conducts an assessment to determine (1) whether intervention is needed, (2) which focus or foci warrant intervention, and (3) which interventions may be most appropriate. Assessment, thus, is a key first step in any clinical endeavor. Intervention without a good assessment is like climbing into the cockpit of a plane and taking off without a sense of where you are starting from and where you are headed. Monitoring is the ongoing collection of data during treatment and is a way of gauging the client’s progress in therapy. Monitoring symptoms is by itself a potent intervention for many clinical problems. Intervention without monitoring is like continuing to fly the plane without knowing your bearing, heading, or track—in short, flying without looking at any instrument nor even looking out the window. When you believe exposure may be part of the treatment plan, the key is a thorough understanding of the specific details of a client’s fears and anxieties. As a result, there are two assessment approaches used when preparing for exposure: (1) identifying and assessing key exposure targets and (2) developing successful fear ladders. 28



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Assessing Key Exposure Targets It is not enough to know the DSM diagnosis to proceed with exposure. For example, the diagnostic category social anxiety disorder only points us in a direction. Relying on the category alone is akin to instructing someone who is grocery shopping to purchase items from the produce section. The person is likely to find the correct part of the store—but so many choices! Thus, with exposure, one must go beyond diagnosis into the idiographic world of the client. A deep understanding of the functional importance of the client’s fears and anxieties is the goal because, in exposure treatment, targeting the client’s specific and often idiosyncratic concerns is the goal. Assessing key exposure targets involves answering several key questions: 1. What are the feared stimuli? 2. How much are the stimuli feared and to what extent do they interfere with functioning? 3. Why are the stimuli feared? An example may help to underscore the importance of a thorough assessment of each target. Consider a client with fears related to public restrooms, especially in school settings. It is relatively easy to imagine a variety of exposure tasks that would target such a fear. However, without understanding the what and why of the situation, it is also possible to be like the shopper in the produce section, selecting eggplant or iceberg lettuce when strawberries are the actual goal. Let’s think it through. Some clients’ fears about bathrooms may be related to their overestimation of the chance of contracting contagious and deadly diseases. For other clients, the bathroom might represent a challenging social setting in which peers may tease or harass them. Another concern could be a strong fear that others will overhear the client voiding themselves. Yet another option might be that the bathroom is a difficult place to escape once inside, making it undesirable for clients who fear having panic attacks. To conduct effective exposure treatment, we need to understand what clients fear and why they fear it. We will cover the what, the how much, and the why next.

The Who Who was not one of the questions mentioned earlier, but I do need to discuss it briefly here, as before you can determine the what, the how much,

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and the why, you need to know whom to ask. In child treatment, we are constantly gathering and sifting through data from multiple reporters: the child, one or more caregivers, teachers, and so on. That means you will want to do your assessment work with multiple people. How should you approach data collection? There are a few ways to go. In many cases, you can conduct the work of generating feared items and rating them with the child and caregiver(s) together in the same room. This can be quite helpful and instructive, as you can use the experience to gather data not only on the items but also on how the family gets along, how much agreement the family has about the concerns, and the various dynamics among the players in the room. As a result, the richness of the data possible when meeting with the family together is often worth the logistical challenges associated with the arrangement. Even when you follow this advice, it is still often quite helpful to meet with each of the people individually to discuss the feared items. There are a few reasons for this approach. First, both child and caregiver may behave differently and reveal different information when alone with you. Many children will disclose more to you alone than they will with the caregiver present, including some novel information that had not come up until this point. Similarly, meeting alone with the caregiver provides them with the chance to disclose a variety of information that they have or will not tell with the child present. Hence, the solo meetings usually pay for themselves with regard to the rich data you obtain. There are other instances in which a conjoint approach is either not feasible or is even contraindicated. For example, with older children and teenagers, the drive for autonomy and the interest in privacy may dictate that working alone with a child and then alone with a caregiver is the best way to proceed. It is also possible that the caregiver–child relationship is so strained that gathering data with both people in the room is more trouble than it is worth. In most cases, the caregiver(s) and the child are your go-to reporters. In some cases, though, you will want to consider adding others into the mix. Is the school an important context for the anxiety? If so, consider talking with the teacher(s). Is the extended family an important part of the child’s life? If so, involve them. Are there other adults who observe the child in important and relevant contexts, like coaches or after-care workers? The point here is that you will achieve a better understanding of the child’s fears if you involve those people who know the child best across different contexts.



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The What Now that we have a sense of who to ask, our first step is to scope out the specific stimulus, or in most cases stimuli, that is feared—that is, the what. You need to rely on as many reporters as possible, starting with the client themselves. For the most part, therapists can conduct this investigation via interview. A first step here is to generate an initial list of the what. I sometimes refer to this as the flyover. The example below gives you a sense of what I mean. “Today we are going to discuss many of the things that you may be afraid of. Our first goal is to come up with a list. For now, we will focus on adding things to the list. Like we are brainstorming. Later, we will come back and talk about each item that ends up on the list so that I understand it better. For now, though, let’s just make a list together.” Preliminarily, it is important to note that for many or even most children, admitting fears is not done freely. Thus, the first goal is much easier to say than it is to accomplish. It can be useful then to establish how normal it is to be afraid of things. If it fits your style, the goal of making the list of the what is often a great time for appropriate self-disclosure. Most, if not all, therapists have had (or even currently have) specific fears. Some may not have risen to the level of a clinical problem; however, they provide you with a way to make an empathic connection and offer the client a chance to see that fears are normal. Sharing those fears can soften some clients and make them more willing to acknowledge their own fears. It can also give them the opportunity to see that they are not afraid of everything. For example, the therapist may share that they’re afraid of spiders; the child may counter that they’re not afraid of spiders. Given that the client is going to, later hopefully, disclose other fears, this statement of nonfear can be a good point to remember later to discount beliefs that the client is nothing but afraid of things. If self-disclosure is not your jam, you can describe others (clients, friends, family members) who have anxieties and fears to help normalize anxiety. When assessing the what, it is important to take a systematic approach and evaluate a broad range of possible feared stimuli. There are some standardized measures that can help you here. A good example is the Fear Survey Schedule for Children—Revised (FSSC-R), an 80-item list of possible feared stimuli that are rated as “none,” “some,” or “a lot” feared. Using an instrument like the FSSC-R can be helpful, especially

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for clients who are reticent, reluctant, or both. Of course, paper-andpencil instruments are limited to probing the specific stimuli listed, while children’s fears can range quite a bit. Still, instruments like these can be an efficient way to help you reduce the universe of possibilities to the galaxy of items relevant to your client. Recall that the point of the what’s flyover is not to get too deep into each feared item. We take that step later. The goal, then, is to make sure you cover all of the relevant topics before you go into depth on a few of them. A few examples may help.

Jasmine Jasmine is a 10-year-old female who is an inveterate worrier. She worries about things ranging from everyday topics such as her grades, her friendships, to her family’s financial status. She also worries about less mundane topics such as global warming and the health status of her friends and her teachers. In addition to her worries, Jasmine has specific fears of a few social situations such as presenting her school work in class, giving a speech in class, and being put on the spot in a social situation. She has almost no fear, though, of everyday social interaction and is also a regular participant in classroom discussions so long as she is not standing at the front of the room. That is, she is comfortable raising her hand and answering questions the teacher may pose but she becomes quite nervous when she must stand in the front of the room and give a speech or present a group project. In Jasmine’s case, there are several fear domains clearly articulated. There are worries, with several subtopics underneath. There are also social concerns, with those also showing some variation. The preliminary list of the what might look like this for Jasmine: Jasmine’s Anxiety List • Worries •• Academic •• Friendships •• Family finances •• Friends’ health •• Teachers’ health •• Parents’ health •• Global warming • Social anxieties •• Performing in school plays



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•• Presenting in class •• Being put on the spot in a social situation

Brooke Brooke is a 15-year-old female with intense social anxiety and occasional panic attacks. Her social anxiety focuses on interacting with unfamiliar peers, especially when they are in a group of mostly peers she does not know. She is also fearful when in a group setting, even when not interacting with others, due to concern that others are observing and judging her. She feels similar anxiety when in public and she must interact with strangers, such as when making purchases at stores or restaurants. With her friends, though, she experiences almost no anxiety and interacts freely and comfortably. Furthermore, in school performance situations, Brooke experiences almost no anxiety. Related to the panic attacks, Brooke has experienced both cued and uncued attacks. The cued attacks almost always occur in social settings with unfamiliar peers and she usually notices them because her heart starts pounding and she feels short of breath. The uncued attacks typically occur at home at night, usually correlated with school work amount. She worries about her grades and performance in school. Brooke noted that her panic attacks greatly frighten her and she also observed that she had started to avoid some social situations to reduce the chance that her anxiety would spike. Brooke’s Anxiety List • Social concerns •• Talking to kids I don’t know in a group •• Hanging out with kids I don’t know in a group •• Talking to kids when I know some of them, but not others •• Hanging out with kids when I know some of them, but not others •• Ordering at a restaurant •• Buying something at a store •• Being seen in public by teens I don’t know • Panic-related concerns •• Heart pounding •• Shortness of breath •• Nights when I have lots of schoolwork • Worries •• Grades and school performance

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These examples provide some sense of the range of items we may identify in assessing the what. Initially, you are brainstorming with the client and their caregivers, and the list may start out relatively modest in size. However, as you expand your exploration into the next question— How much are you afraid?—the list often becomes a bit larger.

The How Much Once we have our initial list of what, our goal is to create a rough sense of the structure of the fear ladder we will build; the fear ladder is a list of feared items arranged in a hierarchical formation by severity of the anxiety. In our two examples, you can note that there were two broad categories for Jasmine and possibly three for Brooke. These categories may end up serving as separate ladders later. For now, though, you need to better understand which items would be on the higher rungs, which in the middle, and which on the lower end. Our lists for Jasmine and Brooke are well organized by category, but we don’t have a sense yet of how to arrange them hierarchically. To do this, we need more assessment. In anxiety treatment that includes exposure, we commonly gauge intensity of fear or anxiety across two dimensions: fear and avoidance. There are other dimensions one could consider and I discuss those later. To get started, we need a rating scale to quantify the two dimensions. For ease of communication in the book, I will focus on a scale that ranges from 0 (none) to 10 (extreme). However, bear in mind that the actual scale is not important. You can use 1 to 5 or 1 to 100 or 1 to 1,000. You don’t even need to use numbers with the client: a therapist can create a gradient of faces or colors or any other stimulus that can be used to convey a range of intensity. If you choose not to use numbers, you will need to make sure you can convert the picture to a number (i.e., the pictures must be arranged in a standard order). With a 3-year-old in our clinic at VCU, we used a thumbs-up (meaning no anxiety) or thumbs-down (meaning high anxiety) scale, eventually developing an intermediate thumbs-middle rating for medium anxiety. More important than how the client gives the rating is that the client has a clear understanding of what they are being asked to report. The child, caregiver, or other reporter needs to understand that the scale includes a range of possible choices and that one end of the scale is “extreme,” with the other being “none.” Ideally, the scale is built in collaboration with the reporters. And a good scale always includes clear anchors for some of the spots on the scale.



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A quick example may help. Therapist: Awesome job, Jasmine. Look at our scale. The low here is a 0 and the high is a 10. Let’s talk about what a few of these mean before we start talking about your list. What do you think a 0 or a 1 should mean? Jasmine: That is like no anxiety. Therapist: So what is an example of that? Picture a time when you were at a 0 or 1. Jasmine: Like when I am with my cat. She is super sweet and purrs when we hang out in my room. Therapist: Perfect. So this is the you and your cat hanging out level of anxiety. (Draws a picture of a cat near the bottom of the scale.) Now how about here—around the 3 to 4. Jasmine: Oh, that is a bit higher. So I am starting to get a little nervous. Therapist: Can you think of an example? Like a time when the anxiety was up just a little bit. Not too bad, but not calm-kitty level either. Jasmine: Well, like when the teacher is starting to ask kids in class to come up and do a math problem. I get a little worried because she might call me. Therapist: Great one! (Draws a teacher and a chalkboard near the 3–4 range.) It has not happened yet so the anxiety is coming toward medium. Rating scale in hand, you spend time working with the client and their caregivers to rate the two dimensions of each stimulus you discussed: fear and avoidance. The first dimension is fear (or anxiety). The word choice here is not important and ideally you are using the word the client or the family uses. It could be “scared” with some clients, “fearful” with others, or “nervous, stressed” with still others. Regardless, the goal with this rating is to understand how afraid the client is of the stimulus—that is, how much fear they experience when they encounter the stimulus. This dimension is important to understand because it helps you to begin to understand the relative rankings of different stimuli, key data for the development of a fear ladder. The second dimension to gauge is avoidance. Here, the aim is to understand how likely the client is to avoid the stimulus. Avoidance is

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an important dimension because it can be a key determinant to the relevance of the stimulus to the treatment plan. As you may recall, avoidance is an effective but problematic anxiety management strategy due to negative reinforcement. The negative reinforcement trap of avoidance is a major driver of anxiety-related problems, and as a result is an important target for anxiety treatment with exposure. Consequently, assessing which stimuli are most avoided is an important goal of assessment. There are other potentially relevant domains to assess for how much fear. Interference or impairment is one additional and important one. Impairment comes in many forms. Academic impairment is common in child anxiety, with anxious children missing school due to anxiety or performing poorly on tests because of anxiety. Anxiety can also impair social relationships with peers—and not just when the focus of anxiety is social. Children who worry or who have intense fears may also experience challenges in relating to their peers. Another domain of impairment is family relationships. Child anxiety can be trying or anxiety-producing for caregivers, straining familial happiness. And finally, anxiety can lead to intense personal distress. I often think of this dimension as the “silent impairment.” Some kids are able to keep their anxiety deeply contained so that it only troubles they themselves. Understanding which items from your what list are linked to greater impairment is another way to help order the list as you approach building the ladder. Another possible variable to measure is the ubiquity of the stimulus. Here, I mean how commonly the client encounters the stimulus in their everyday life. Some stimuli may be intensely feared, heavily avoided, and only rarely encountered. As an example, many people are quite afraid of snakes. However, for many of us, snake encounters are quite rare. Thus, even intense and highly avoided fears that are not commonly encountered may end up as a lower priority for exposure efforts. A final variable to consider measuring with regard to the feared stimuli is the relative importance or relevance of the stimulus for the family. It is possible that the construct will be captured when discussing impairment. In case not, it is important to consider the salience of items to the family. By “salience,” I mean the extent to which the stimulus represents what the family believes to be the key treatment goal(s). It is possible to imagine a client with intense fears with high levels of avoidance but that are not considered as important to the family as fears that may be in the more moderate range with more moderate avoidance. As one example, a child may have intense fears of speaking in public such as in a restaurant but the family may prioritize speaking in school though that fear may be of lower intensity.



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The Why The last assessment step before assembling the fear ladder involves assessment of the why—that is, Why is the stimulus feared? When I am talking about the why, I am not necessarily talking about the absolute origin of the fear. It can be very difficult to establish the true cause of a given fear. Some readers may recall an episode of the television show The Simpsons wherein one of the characters, Marge Simpson, attends therapy to treat her fear of flying on an airplane. Through the course of treatment, she recalls learning that her father was not a pilot as he had claimed but was instead a flight attendant. Initially experienced as a major insight, the episode continued to show numerous other memories of Marge’s that may have contributed to her fear, including watching her toy plane catch on fire and being chased by a crop-dusting plane across a field. The humorously made point here is that the origin of a fear can be quite complex and rarely can be reduced to one critical moment. The good news is that we need not know the precise origin of the fear to use exposure. Instead, we need to understand the function(s) the fear serves and why the fear is maintained in the child’s current context. There are a few key domains to probe to accomplish the goal. It is not enough to know that a child is afraid in social situations or has separation fears. We must build a stronger picture of the feared so that we can begin to reveal possible reasons for the fear. An example here will make clear how the gathering of details can happen. Therapist: OK. Next I want to start to get an idea of the kinds of situations that make you nervous. Like, for example, we talked about how it is nerve-wracking when you have to talk to a kid you don’t know. What’s an example of that? Brooke: Um, like any time I have to talk to someone I don’t know, I just get really freaked out inside. Therapist: Sounds uncomfortable. Tell me about a time this happened recently? Brooke: Well, yesterday, I was in the lunchroom early because I got out of class early and none of my friends were there so I was sitting by myself. And this girl I don’t know sat down near me and I was like, Oh no. Therapist: Great example! I can picture that one really well and I know what that is like. (They discuss further social examples in unstructured settings. A few minutes later . . . ) What about in the classroom

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for academic stuff? Like say a class project where you have to present. What is that like? Brooke: If I am ready, then that is no problem. I know that is weird, but I don’t mind doing a presentation if I am prepared. I don’t get freaked out. Therapist: What if the other students can ask questions? Does that make it harder? Brooke: A little bit. But as long as I have my notes and stuff, that kinda thing is fine with me. Therapist: What if you are not totally prepared? Brooke: Well, that is trouble. Therapist: Tell me more. What happens? Brooke: That is the kind of situation where I start getting really freaked out. Therapist: Like panic stuff? Brooke: Yeah. If I am not ready, I start to get breathing funny and my heart is going crazy. We can see here that the therapist is beginning to get a better and richer understanding of the anxieties that Brooke is experiencing. Notice how the social anxiety is largely focused on interacting with peers in less structured and nonacademic situations. And notice, also, that the academic situations seem a bit less social- and more panic-related. Of course, these details are great but they are not enough to help us get a better feel for the why. For that, we need to spend some time assessing the client’s and often the caregiver’s understanding of the reason(s) that drive(s) the fear. The information we are looking for with this step is what will help us later develop the most appropriate items for our exposure tasks, items that are maximally personalized for the client’s particular brand of anxiety. Let’s drop back in to the therapist’s work with Brooke. Therapist: I want to switch gears a bit here and see if you can help me understand a bit more about these situations we have been talking about. (Reads from notepad.) Let’s take a look at this one: when you are with a friend and another girl you don’t know joins your conversation. (Pulls out a piece of paper with the three parts of anxiety on it: thoughts, feelings, and



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actions.) What kinds of thoughts, feelings, or actions happen for you in that kind of situation? Brooke: What should I start with? Feelings? Or thoughts? Therapist: Your choice. Brooke: OK, well, I usually feel pretty nervous, like I get the dry mouth thing and my hands get sweaty and my heart goes crazy. Therapist: Good description—that sounds uncomfortable. What about your thoughts? Brooke: Like what if she thinks I am a freak? Or she’s gonna notice my hands are shaky and sweaty. Stuff like that. Therapist: You wonder if she will think you are a freak. What does that mean—freak? Brooke: You know, like a crazy loser. A mental case. Like I am the crazy anxious girl. Therapist: I think I get it. So you start to think that she is going to think you are a really anxious person, someone with mental problems? Brooke: Right. Therapist: How about actions? What do you do in this kind of situation? Brooke: Nothing. At least I try to do nothing. I try not to be noticed. Therapist: Why? What would happen if you were noticed? Brooke: Well, she would know I was a crazy person. It would be obvious. The therapist is starting to get a clearer picture for some of the driving thoughts, feelings, and actions for Brooke’s anxiety. With more questions, including conversation with caregivers, we can assemble a clearer picture of the why of the client’s fears. And as a reminder, we are working to establish a tentative theory of the why so that we can design the optimal set of exposure experiences for the client. Our goal is to personalize the exercises as much as we can, and to do that we need to understand the idiosyncrasies of the client’s anxiety. As the picture begins to emerge, we are ready for the next big assessment step related to exposure and arguably the most important: building the fear ladder.

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Building the Fear L adder As was noted in the opening chapter, the exposure therapy approach typically involves gradual exposure, a method that involves progressing through a graded set of items toward the client’s treatment goal. Just as each client’s anxiety is unique and idiosyncratic, each fear ladder is too, as is the number of fear ladders for each client—some will need only one or two; others will need several. First, though, let’s be clear as to what exactly a fear ladder is. A fear ladder is a collection of feared items, arranged hierarchically and organized around a central theme (e.g., social fears related to peers, separation fears related to not being with mother). A ladder starts at the bottom with those items that produce the least fear and rises to those that produce the most. We use the metaphor of a ladder for a few reasons. First, it helps everyone quickly understand that the goal is to climb the rungs of the ladder toward the goal, starting with the lowest rungs. Second, the metaphor is also useful insofar as it reminds the therapist and client of the need to have relatively evenly spaced rungs or items all along the way. The importance of this point will become more apparent shortly.

How Many Ladders? Let’s start with the basics of fear ladder construction. How many fear ladders should I build for each client? Each ladder needs to have a clearly identified focus or theme. As most clients have multiple anxiety themes, we will need multiple ladders. However, it is important to avoid the temptation to create fear ladders for every possible theme for the client. The goal of exposure treatment is not to expose the client to all of their fears but rather to help the client understand the process of exposure so that they can build their own ladders. That is, we are teaching fishing and not giving out fish. The best fear ladders have a single-stimuli focus, as the logic of proceeding up a ladder with related items each session is optimal for making across-trial habituation clear. As discussed in Chapter 1, acrosstrial habituation is essentially the client learning that each time they approach something they are afraid of, their fear gets a little lower. As a result, you will often need to build more than one ladder. Consider the examples of Brooke and Jasmine. For Brooke, the therapist built one ladder that addressed her peer-related social fears and a second one that directly addressed her panic concerns. For Jasmine, the task was more



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challenging. There was clearly one ladder to build related to her social performance concerns. Her worries were where the therapist became stumped; she considered a single ladder that addressed the process of worry but landed on building multiple worry-related ladders based around the themes of family-related worries, friend-related worries, and a third category that Jasmine called “world worries.” How will you know if you need more than one fear ladder? To tackle that question, let me present an even tougher example. Imagine a client who has both Brooke’s peer-related social fears and Jasmine’s social performance fears. You can make the case for viewing all of the items as social and building a single ladder. This could be quite advantageous if there was a link across all of the fears, such as fear of embarrassment. Further justifying a single ladder would be the assessment that the client’s social skills were adequate. In such a case, the items all serve to expose the client to a variety of social experiences, items that provide multiple opportunities to test the hypothesis that others will criticize the client. However, one can also envision separating those items into two ladders. For example, if the client has more limited social skills, focusing on a social performance ladder may prove an easier way to build social skills in highly structured situations before advancing to a ladder that includes social situations that are more free-form. In addition, having two ladders in this case has the advantage of creating a clear “curriculum” through which the client is advancing. Staying focused on performance tasks for several weeks can lead to the strong development of the social performance “muscle.” The second ladder of peer-related interactions focuses on overlapping and distinct “muscle” groups. Either way, a main goal is to keep the number of fear ladders as small as your understanding of the what, how much, and why of the client’s fears will bear. Hence, the rule of thumb is two to four ladders total. In conducting exposure therapy (and likely, in conducting most therapy), focus is an important friend. Exposure therapy is built on the foundation of learning theory. Thus, to facilitate optimal learning, it can be best to identify and practice clear learning goals. Also, remember that a client may only remain in treatment for a short time. Focusing on a finite set of items in one fear ladder can ignore some of the client’s complexity; however, doing so acknowledges that time is scarce. Also, as will be discussed in more detail in Chapter 4, a meta-goal of exposure is to help the clients learn and develop mastery with the exposure process itself—that is, to learn how to design exposures for themselves. That way, your emphasis is not on covering every fear they have and

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instead on helping them see how the exposure toolbox can help them solve almost any fear they encounter.

The Number and Spacing of Rungs As to how many rungs per ladder, there is also balance to be achieved between having so few rungs that clients are leaping between them to ascend and having so many that after climbing for several rungs, they look down and see that their feet have barely left the ground. The sheer number of rungs is less important than their spacing. A good way to think of this is to have some rungs that are low, some that are in the middle, and some that are up high. Initially, 10 rungs can be a good goal, especially if you are able to have them relatively evenly spaced and relatively equally distributed across low, medium, and high. Consider the ladders pictured in Figure 3.1. Each has the potential to get you over the wall. However, many people will choose D (and some even prefer F) over the others. You don’t have to have your ladder fully formed before you start using it. The ladder is meant to be a guide for exposure treatment and you are meant to change and adapt it as you move forward. As will be discussed throughout the book, assessment never ends, even though you may start exposure treatment in the middle of it. You should be regularly

A

B

C

D

E

F

Reprinted by permission from Prac�ceWise (www.prac�cewise.com)

FIGURE 3.1. Different types of fear ladders. Reprinted by permission of PracticeWise (www.practicewise.com).



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updating and adjusting your understanding of the client’s anxieties. As a result, each fear ladder shifts a bit as you see how progress on the first few rungs proceeds.

Items Should Be Practicable When converting the raw materials from your assessment of the what and how much into the ladder, you must ensure that the items you have are practicable. That is, each item needs to be something that the client can practice either in your work space, at home, or in public. Ideally, the items should be relatively easy to make happen. A few examples may help. On the easily practiced end is any kind of simple straightforward social interaction. Saying hello, introducing oneself, asking simple questions, starting or ending conversations, making small-talk, ordering in a restaurant, and asking for help in a business are all excellent and easily practiced items on the fear ladder of someone who has social anxiety. On the other end of the spectrum, more difficult-to-practice items for someone with social anxiety include social interaction with specific individuals who are difficult to access or who may be difficult to predict. Imagine a client who is fearful of speaking with a cousin who lives in a distant state or a client who is afraid to speak to a particular classmate who is not well known by the caregiver. These more challengingto-implement items need not be avoided. However, it’s better to fill the ladder with items that can be practiced with ease.

Ordering the Items Once you have your items assembled and divided into a set for each ladder, your next achievement is to order the items. In some cases, it is just a matter of taking the items and placing them in order by rating. There is one challenge that often ensues, and some of you will have already predicted it. You will have multiple ratings for each item such as from the child and the caregiver. You need to determine how best to integrate these data. Averaging them is often an efficient approach, especially if the ratings are not wildly discrepant. Alternatively, you could choose to emphasize one person’s ratings over the other’s. In some cases, you may have good reason to trust the caregiver’s ratings over the client’s. Perhaps the client has reported no fears at all. Or they have reported that all items are at a 10 out of 10. In such instances, the client’s report is important, must be acknowledged, and needs to be addressed. However, it may not be immediately useful for planning exposure tasks. In other

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instances, the caregiver may lack insight into the client’s anxiety and thus you may choose to emphasize the client’s perspective. Once you have ordered your practicable items across your fear ladders, your final step involves pruning the items down to a manageable number for exposure treatment. Aiming for about 10 items per ladder is generally a good plan; this number allows you to have enough items to cover the whole rating scale while still accomplishing most of the items in treatment. A common problem is having too many items. The number of items can increase rapidly as you learn how various dimensions influence the client’s fear and anxiety. Consider Brooke’s example in the list below. We started with seven items on an initial assessment pass. A typical way to circle back through the initial list to get more details is to go item by item. However, doing so often ends up leading to each item quickly multiplying into several, ballooning our initial list of seven to more like 50. Original Items Associated to Social Interactions with Peers • Talking to kids I don’t know in a group • Hanging out with kids I don’t know in a group • Talking to kids when I know some but not others • Hanging out with kids when I know some but not others • Ordering at a restaurant • Buying something at a store • Being seen in public by teens I don’t know You can see how that happened just with the first item in the following list. Expanding on the First Item Only: Talking to Kids She Does Not Know in a Group • Talking with one girl I don’t know • Talking with one boy I don’t know • Talking with more than one girl I don’t know • Talking with more than one boy I don’t know • Talking with more than one kid of a different gender I don’t know • Just listening in a group conversation with a girl I don’t know • Just listening in a group conversation with a boy I don’t know If you let your items reproduce like rabbits, your fear ladders will look like the example with many rungs in the earlier figure. As we expand each of Brooke’s initial list of items, we may choose to focus on



The Fear Ladder, Assessment, and Monitoring  45

one or two of them as the best exemplars for that domain. In pruning, you do your best to create a manageable set of items that hit the low, medium, and high. Here we present the initial final fear ladder for Brooke’s social concerns. Brooke’s Initial Social Concerns Fear Ladder • 10: At lunch I approach an unknown girl and start a conversation. •   9: At lunch with one unknown girl, I say hi and ask a few questions. •   8: At lunch with two unknown girls, I say hi and answer a few questions. •   7: At lunch with one unknown girl, I say hi and answer a few questions. •   6: At lunch with one unknown girl, I say hi and that’s it. •   5: At lunch with one friend and one unknown girl, I say hi and answer a few questions. •   4: At lunch with one friend and one unknown girl, I say hi and that’s it. •   3: At lunch with one friend and one unknown girl, I don’t talk. •   2: At lunch with two friends and one unknown girl, I nod or smile only. •   1: At lunch with two friends and one unknown girl, I don’t talk.

Tips for Evenly Spaced Rungs When inspecting our raw materials (i.e., the feared stimuli), we may find that they are practicable but not as nicely spread across low, medium, and high as we would like to see. There is a strategy to split one item into many, a strategy that does not require you to understand nuclear fission. All you need is a mind that can identify the dimensions across which our existing items can vary. The dimensions include (1) number, (2) intensity, (3) context/location, (4) proximity, (5) characteristics of nonhuman stimuli (e.g., size, appearance), and (6) characteristics of human stimuli (e.g., sex/gender, age, ethnicity). You vary the target stimulus across one or more dimensions, and suddenly you have multiple items that vary in their anxiety production. As an example, let’s go back to Brooke. An item we have for her ladder is saying hi to an unfamiliar person who has joined her lunch table. Her rating for that item was a 5 if she was alone and the person joined

46  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

her. Let’s see how we can dial the rating up or down by varying the item across a few relevant dimensions. We could ask her if the rating would change if a friend was already present. Brooke’s answer: it is easier, more like a 2 or 3, depending on the friend. With best friend, it would be a 2, with other friends, a 3. We could also explore if the rating would change if more than one person joined the table. As the number of people joining the table who are not well known by Brooke increases, so does her rating. What about gender? What if the person who joined the table was a boy? For Brooke, that makes things even worse. A single unknown boy rates an 8 on the rating scale. You can quickly see how this simple item-splitter can help you multiply your raw materials for the fear ladder you will build. We have made great progress in assembling your fear ladder builders kit. You have learned about several key parameters of the fear ladder. And you have a lot of ideas now for how to generate, organize, order, and prune your items into a small set of ladders. Before closing out our discussion of the fear ladder, I turn to one final topic, troubleshooting fear ladders when things get tough.

Common Challenges in Building Fear Ladders

Working Creatively When the Client Is Challenging Readers of the book may be wondering, “OK—I get the point here— but that approach won’t work for some of my clients. They won’t talk or they can’t sit still.” Indeed! Some clients are reticent or even mute. Some are hyperactive or disruptive. Others have limited insight into their fears. For these and other challenging clients, a conversation about feared stimuli is not going to be easy; not at all! The good news is you get to try a lot of creative ideas! For some clients, you can consider a physical approach to item generation and fear ladder building. I worked with an excellent therapist who used yellow Post-it notes and wrote out many different items solicited from the client and the client’s parents. The therapist then asked the clients to arrange the Post-it notes on the therapy room door with the more difficult items going toward the top and the easier items going toward the bottom. This physical manifestation of the fear ladder allowed the therapist to see the gaps in the ladder and it engaged the client in an enjoyable physical activity. The fear ladder became a fun, physical project instead of a talking exercise. Some clients are much more pensive, sedentary, and reticent; they may be less likely to respond to physical activity. For those clients, lean into your creative side and engage the client through media like drawing,



The Fear Ladder, Assessment, and Monitoring  47

collage, photography, or even sculpture using material like Play-Doh or Sculpey. Use colors or shapes to represent ratings. I know a therapist who worked with the client on a project of making leaves for a tree. Images from magazines were added to the leaves to represent items and the leaves were arranged on a posterboard tree in a hierarchical fashion. Instead of climbing a ladder, the client climbed a tree! In short, when generating items and building the ladder, be creative and individualize the process for your clients. Last, let’s turn to some other common challenges encountered.

When Items Are Bunched at the Top, Bottom, or Both Recall Figure 3.1 and its six fear ladders. Most of us would prefer climbing the one with the gradual and evenly spaced rungs. Building such a ladder increases the chances of success of exposure. However, there are a few common challenges in building strong fear ladders. The first of these is when the items are all gathered tightly at the top and bottom of the ladder. This is quite like ladder C in the figure. With a ladder like this, you have a great place to start and a great place to end but oh my—how to navigate that jump in the middle! The solution to this problem is often in identifying items that are just a bit easier than the items at the top or just a bit tougher than items at the bottom and then slowly working your way into a nice set of middle items. I mentioned this basic process of “dialing up” or “dialing down” an item already and will return to it later when I talk about actually doing exposure. Needless to say, for those clients who can only identify top and bottom rungs, you definitely earn your money helping them find the middle. The work often involves identifying the dimensions that can be manipulated to gently increase those lower rungs upward in difficulty and/or gently ease the difficulty of the upper rungs. Another challenge is the fear ladder with rungs only at the top. These are the ladders where nearly all of the items are rated as an 8, 9, or 10. Here you need to explore a few hypotheses. First, it may be that the rating scale was not adequately understood. You can test this by having the client rate items that you know not to be scary to the client, starting with items that are likely to be enjoyed, such as prized foods, toys, games, or people. These items represent the floor, even below the first rung of a ladder. If the client understands that concept, you then probe for items that walk you up one rung. Ideally, you stay within the realm of the feared stimulus, though establishing low items may require you to stray from that goal. One possible lower rung to consider is “building this fear ladder” or “talking about fears.” The act of talking about

48  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

feared stimuli is likely to evoke anxiety. In most cases, the item would be rated on the lower part of the ladder, as the client is demonstrating the ability to do the item. As you begin to fill in the lower rungs of the top-heavy ladder, you may notice the discomfort of the client in talking about the items reducing somewhat. You can reassure the client that none of the items will be practiced today. Sometimes, the client may worry that you will start making them do feared things right away. A final challenge that is common is the ladder with items only at the bottom. This is generally because the client denies that anything makes them anxious. You are not likely to have this situation for long, as the caregivers should at least be able to present with you some items that are higher up on the ladder. Unfortunately, though, even with this evidence, some clients will disagree with their caregivers and insist on not experiencing any anxiety about any of the items. In these instances, you are often in the position of relying on the caregiver to help define the middle and upper rungs of the ladder. This is less than optimal, since the exposure tasks themselves are conducted with the client. Caregivers can have a good understanding of their child’s concerns, and yet there is no one who knows better than the child themselves. Thus, the approach taken must be more cautious, as your data are less than ideal. I had the opportunity to work with a client like this early in my training. She was a 14-year-old who lived with her biological parents. Her parents reported intense worries about schoolwork and academics and a strong separation anxiety from her father, with whom she had a close relationship. All of these data were from the caregiver report. The client refused to acknowledge any anxiety about any of the items I had discovered from her parents in our assessment. I tried a variety of engagement and relationship-building approaches to see if that would help us open a dialogue on her concerns, but this was largely to no avail. However, as her parents were committed to therapy, she attended weekly and participated. Our exposure sessions were awkward, as we practiced items from a fear ladder she did not fully acknowledge as creating fear (though it was obvious to me that she was anxious). She made progress per her parents’ report; she made none by her own report. We still managed to complete many sessions of exposure and work our way through a fear ladder.

The Fear Ladder as a Progress Measure There is one last point to make about the fear ladder before we transition to doing exposure. The fear ladder is not only a good treatment planning tool. It can also be a tool for measuring treatment progress.



The Fear Ladder, Assessment, and Monitoring  49

Clients present to psychological treatment most often because they are suffering. To alleviate their suffering, we use a variety of interventions with the hopes that they will improve functioning and reduce symptoms. Too often, we rely on the client’s subjective comments at each meeting. We ask how things are going and they say “Good,” or “Fine,” or “Better.” And we keep on doing our treatment plan, assuming some validity in their reports. Although this is a somewhat reasonable and undeniably practical approach, it is fraught with weaknesses as the sole way to measure progress. The problems are these. First, clients may want to report that things are going well to please the therapist. Indeed, time with a therapist may be the most pleasant time a client spends in the week. Where else do clients get to be with someone who is kind, a great listener, and supportive? Alternatively, clients may report that things are not going well or that new problems are emerging to avoid ending therapy. Another problem is that like all of us, clients can struggle with perspective on progress. Most them focus on their current experiences and rarely reflect on how much they have grown or learned or progressed. We are often surprised when someone who has not seen us in a while remarks upon a change (e.g., haircut, getting taller, new clothing style) to which we have already become accustomed. Thus, we need some tools to monitor progress beyond asking for a subjective read on that progress. Measuring progress when doing exposure therapy is important. Of course, as the client moves up the fear ladder, you can see progress almost literally. A rung that heretofore was unimaginable is now below the client as they climb toward the top. A good way to quantify that progress is to readminister the ratings of the fear ladder you built initially with the client every other week (or so). An example is presented in Table 3.1. Data in the table were gathered at the second and eighth sessions. Note that the total score may be the best index of progress and ideally will decline over time. A key is to retain the same rungs for the ladder each time. That way, the decreases in anxiety ratings reflect changes to the same items. In this example, individual items’ ratings were reduced— that 10 is not a 10 anymore—and the overall total dropped a full 19 points.

A Few Words on Other Progress Measures In addition to using the fear ladder as a progress indicator, other suggestions include use of standardized measures like the Revised Children’s Anxiety and Depression Scale (RCADS), the Scale for Children’s

50  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS TABLE 3.1.  Fear Ladder Ratings as an Outcome Measure Session 2 rating

Session 8 rating

Talking in a group conversation with people you don’t know and without your friend there

10

 7

Talking in a group conversation with people you don’t know and with your friend there

 9

 7

Talking in a group conversation with people you know but without your friend there

 8

 5

Talking in a group conversation with people you know and your friend there

 7

 5

Introducing yourself to a new peer without your friend there

 6

 5

Introducing yourself to a new peer with your friend there

 5

 3

Telling a story about your day to a friend

 4

 2

Asking your friend a question

 3

 2

Saying hi to a friend outside school when they are with other peers you don’t know

 3

 1

Saying hi to a friend in the classroom

 2

 1

Saying hi to a friend in the hallway

 1

 1

Total

58

39

Item

Anxiety and Related Emotional Disorders (SCARED), and the Multidimensional Anxiety Scale for Children (MASC). All three represent dimensional measures of anxiety, capturing several different aspects of anxiety, with the first two pegged to the DSM anxiety disorders and the latter based on a multidimensional theory of anxiety. The first two are available at no cost; the third is available from the publisher. There are also several more diagnostic-specific measures; for a thorough review of anxiety measures, see Southam-Gerow and Chorpita (2007). Although standardized instruments are preferred because they have empirical support, they are typically lengthy and thus not ideal for frequent administration. Instead, it can be useful to develop what we call idiographic measures as well. These are measures that gauge specific problems for a specific client. They lack the empirical basis of standardized measures but are more individualized and when designed properly, easy to administer.



The Fear Ladder, Assessment, and Monitoring  51

A simple weekly anxiety rating can be a practical choice, though a caveat warrants mention. It is generally best not to ask the client for their anxiety rating in sessions. In some cases, that may be relevant (i.e., the client is fearful in sessions) but usually it is anxiety outside of session that is the focus of treatment. Thus, a solid approach for a weekly rating is to collect an average of daily anxiety ratings collected during the week from both the client and their caregiver(s). Of course, one need not measure anxiety. Weekly ratings of various related constructs may be useful and pertinent, including (1) avoidance rating (how many times stimuli were avoided or how intensely avoidance occurred); (2) approach rating (a rating that is the positive opposite of the avoidance rating—for example, number of times feared stimuli were approached), or (3) coping rating (i.e., a rating of how well the client coped with their anxiety). Of course, the readministered fear ladder is also an excellent idiographic measure. Collecting both standardized and idiographic measures during treatment allows you to keep an eye on progress toward goals and to assess as clearly as possible what next steps in treatment are most sensible. Up to speed on assessment, fear ladder development, and progress monitoring, you are now ready to start doing some exposure.

CHAPTER 4

Conducting Exposures The Basics

I

n this chapter, I focus on the nuts and bolts of how to do exposures. The chapter presents general exposure procedures; Chapters 6–10 explore the variations of the procedures associated with different anxiety diagnostic groups. In Chapter 5, I also explore the important question of when and how to integrate coping skills, like cognitive skills and relaxation, into an exposure approach. Bear in mind that because the book focuses on exposure and its variations, the chapter on coping skills will provide a brief overview only. In exposure, the game plan is derived from the fear ladder already discussed (see Chapter 3). You and the client work your way up the fear ladder. The focus of each session is, first, to review the previous week’s exposure, possibly considering a reprise of that item in the current meeting. You readminister the fear ladder ratings to recalibrate the ladder. And then you collaborate with the client to identify the next item on the ladder to tackle. This is what my colleague Bruce Chorpita (2007) likes to call the “lather–rinse–repeat” nature of exposure therapy. Given how technically difficult exposure therapy can be to carry out, the procedure itself is oddly simple and straightforward. I can break it into three main parts, though the three often flow together. The first part is preparation, a step in which the client and therapist get ready for the exposure that is about to take place. The second part is the actual exposure: the client approaches and engages with the feared stimulus or situation. The last part consists of a debriefing, during which the client and the therapist discuss what happened and then move to repeat the whole process. When training therapists to do exposure, I sometimes 52



Conducting Exposures: The Basics  53

refer to this by using a sports metaphor. You huddle up and make a plan. You do the plan. And then you huddle up again to talk about how the plan went. Then you make another plan. And so on. Repeat. Let’s take a look at each of these three steps in a bit more detail.

Preparation Preparation involves the following: selection and clear definition of the exposure task, getting preliminary ratings, providing a walkthrough of the task, and, if needed, offering anxiety management skills to help move things forward.

Select the Task When you first start exposure, the selection of the exposure task is highly dependent on the ratings from the fear ladder and these are often so highly subjective in early sessions to make them an unreliable guide. No one really knows how afraid they are of something until they have to face it. When a client rates, in the abstract, what their level of fear would be if they looked at a photograph of a spider, they may give it a 3 out of 10. However, when the therapist brings the photograph of the spider out of their briefcase, even before the client sees the photo, their experience of anxiety may be quite a bit higher than the 3. They can be quite surprised by how afraid they are of something when actually faced with it. In some ways, we can all be quite a bit braver when making ratings removed from the situation than how we will feel when we are actually in the situation. The opposite can also be true; when faced with the stimulus we can be less afraid than our ratings had predicted. That is why choosing the tasks early in therapy is challenging. You are relying upon a fear ladder for which the ratings may not be entirely valid. Choosing an exposure task for a client gets easier with each session. A good rule of thumb for selecting an exposure task in early treatment is to aim for success at all costs. The exposure task needs to work, which means that the clients experience an anxiety reduction. You want the first few times that you do exposure to go so well that the client is assured that the procedure works (and that you know what you are talking about), and that they can handle it. Start low and go slow at the beginning. Selection of the exposure item is a collaborative process. The therapist and the client, and in some cases the family, review the fear ladder

54  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

and have a conversation about which item would be a good next step. Where should you go next? What will you focus on today? The therapist can be fully transparent. Let the client know you want to pick something that is not particularly scary. It needs to be fear-inducing but it does not need to generate high levels of fear, at least in the beginning. As you see how the client does, you ratchet up the difficulty. When you select an exposure task, it is important for you to be able to dial the difficulty of the task up or down to adjust the challenge level. This ability is particularly pertinent early in exposure, when you are not sure how valid the clients’ ratings are. Your ability to dial the challenge level up or down on the fly will make a big difference. Practice and preparation are important here. You will want to consider different variations in advance rather than trying to make one up in the moment. Some of us are easily able to improvise, but for most of us it is a good idea to consider in advance how each item on a fear ladder could be made somewhat easier or somewhat more difficult. Let’s look at an example of the dialing up or down procedure. The client is Angel, a 13-year-old girl who is socially anxious and afraid to introduce herself to others. She even feels challenged saying hello to people she doesn’t know well but with whom she is familiar, including staff and teachers at her school. An early item on the fear ladder was to say hello to the receptionist at our clinic. Angel has given this task a preliminary rating of a 3. She has been coming to the clinic now for 5 weeks and has seen this particular receptionist each time. Angel is not only familiar with the receptionist, but the receptionist is also friendly and greets Angel each time she sees her. The therapist was quite confident that Angel would succeed in this task of saying hello to the known quantity of his friendly receptionist. Still, despite the confidence of the therapist, the supervisor insisted on identifying ways to make the task easier and ways to make it harder, just in case things did not proceed as expected. For this particular task, the team landed on a few different ways to dial it down: (1) wave hello without saying it, (2) nod at the receptionist, or (3) make eye contact only. These easier tasks represent approximations of the desired behavior. This is a key point: we therapists must be sensitive to progress, even incremental steps. Each step makes a difference, the same way that one pebble alone is not much whereas a stack of them can divert a stream. The fear ladder that the client climbs is not always the one you built at the outset. The rungs may be closer together. You may spend a lot of time on one particular rung. But as long as the client is climbing and remains steady in their progress, they will keep getting closer to the goal.



Conducting Exposures: The Basics  55

As a result, your job is to be aware of that incremental progress so that you can maintain your own morale as well as that of your clients. With Angel, the therapist landed on waving, nodding, or, at worst, eye contact as the dial-it-down option. But what about dialing it up? Imagine that Angel easily says hello and rates this as a 0 right away. They repeat this a few times to ensure that the rating remains low and indeed it does. If Angel does not seem afraid at all of saying hello to the receptionist, score a point for the client in making progress and score one for the therapist in picking a friendly receptionist. At this point, one could simply move to the next item on the fear ladder. The therapist could also dial up the current item, enhancing or making it more difficult. As a few examples, the therapist could require making good eye contact, using a strong, assured voice, or add an advanced social interaction task, such as asking how things are going. Each of these enhancements increases the difficulty of the task somewhat but stays in the same basic category of the item.

Clarify the Task Once the task is selected, one must clarify what the task is. The therapist and the client need to be clear about what exactly is being asked of the client. Bear in mind that during the selection of the task, you may already have come to an understanding of this. Thus, this step is merely a restatement of the task. However, in many cases, it is worth the effort to clearly define the task for the client. Why this is important will shortly become apparent. There are two things that humans dislike that lead almost inevitably to anxiety: unpredictability and uncontrollability. Try to reduce unpredictability and uncontrollability as a means of managing anxiety as often as you can. Given that you are placing your clients in a situation that is guaranteed to create anxiety, you can reduce some of the uncertainty for them by making very clear what the parameters of the task are and also are not. Hearken back to Angel who is going to say hello to our receptionist. The task may seem obvious but you can eliminate more uncertainty by explicitly spelling out the task. For example, you might say something like the following: “Let’s walk through the steps of the practice today. One, leave this room through the door. Two, walk down the hall and approach the receptionist’s desk. Three, stand in front of her. The big one is next: when she looks at you, say, ‘Hello’ You then wait for her to

56  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

say something back. She will probably say ‘hi’ too. Then, you come back down the hall. I will be standing here in the door.” This example is a simple one, but generally tasks become increasingly more complex. The most complex often involve social interactions that are unpredictable. An example might be to engage in a conversation. It can be difficult to articulate clearly what the expectations are given that the other person’s response in this situation is impossible to predict. In these complex cases, the goal for the clarification process is to articulate for the client what their deliverables are. That is, what the bar for success is for the client. In the conversation example, success may be to introduce one or two distinct topics of conversation. If that is the bar, you may want to pick those in advance. Alternatively, success could be to remain in the social situation and to contribute to it for a specific period of time, say 3 minutes. As noted, a primary reason for being clear about the task has to do with reducing the anxiety of the client about the task as much as is possible, given that the task itself will be anxiety-provoking. Rarely do you try to make the task a surprise for the client. Later in the book, I will consider situations when you may want to use surprise in exposure. However, in general, be open about your plans with the client, letting them know everything. Some clients are very skillful at finding ways to avoid things they are afraid to do. But if you make the task very clear, you reduce the opportunity for clients to cleverly find ways to avoid the task or reduce its scope. For example, explain that while you will be there during the task, you will not respond to any questions or requests.

Take Ratings Once you have chosen and clarified the task, you need to establish the rating. Ratings are your primary guide when conducting exposures. Think of it like a GPS when you are traveling in a wholly new city and must get around effectively. A rating lets you know where you are, how much progress you’ve made, and whether you’ve arrived and can move to the next item on the ladder. Remembering to take the rating is more difficult than you might imagine. Both inexperienced and experienced therapists forget about the ratings from time to time. In the flow of a session, after some good hard work at picking a task and clarifying it, the momentum often leads us to launch right into the task. This can be particularly true for clients who



Conducting Exposures: The Basics  57

are anxious and who subscribe to the notion of “just get it over with.” Bear in mind that the point of the exercise is not just to get through it, but rather to attain mastery over the situation by proceeding deliberately and mindfully. Ratings help you be both deliberate and mindful. They help you and the client to slow down and look inside. They also help you be mindful of progress, even small progress. In short, once you have agreed on the task, take a rating. It’s that simple. “What’s your rating right now about doing this task?” Rating noted, you’re ready for the next step.

Rehearse A rehearsal is a walkthrough or dry run of the task. Rehearsal can be useful in reducing anxiety early in exposure and also in preparation for particularly tough tasks. The rehearsal serves multiple purposes. First, it helps the client practice the behaviors that are expected in a lower anxiety context. Rehearsal also allows for further clarification of the task, allowing you to see how the client has interpreted your instructions. The rehearsal also enables you and the client to identify and foresee possible unanticipated challenges. For example, you might say to the client, “When you say hello to the receptionist, what if she asks you a question? What can you do then?” Or “What if when you order your drink at Starbucks, the barista asks what size you want?” Rehearsal will look just like the exposure task, except that you and the client can comment on it throughout. First, you have to select who will play the role of the client in the rehearsal. It generally reduces anxiety if you play the client role once or twice in rehearsal before the client practices. By playing the role of the client, you unlock the potent modeling intervention. After one or two iterations, you change roles. An example will help make this clearer. Let’s return to Angel, the 13-yearold with social anxiety. A task on her fear ladder was to approach and say hello to the receptionist. After taking an initial rating, the following interaction happens: Therapist: OK, before we head down to the reception area, let’s rehearse a few times in the office. For our first practice, who would you rather be: yourself or the receptionist? A ngel: The receptionist. Therapist: OK—great. Her name is Kitty. I will be you, Angel. Remind me what my goal is? A ngel: Um, what?

58  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS

Therapist: What is the exposure task I am supposed to do? A ngel: Oh, right. You have to say “Hi” to the receptionist. Use a good voice. And look at her. Therapist: Sounds . . . kinda scary. I think I can do it, though. Let’s get your guess for how Kitty will act. What do you think Kitty will be doing when we approach her? A ngel: I don’t know. Maybe sitting at her desk. Therapist: Sounds right. Let’s pretend this table is your desk. And you can sit at that chair. What will she be doing do you think? What have you seen her do? A ngel: I don’t know. Like working on her computer. Therapist: Sounds about right. Let’s pretend this book is her computer and you can be working on it. . . . Now one more thing: what do you think Kitty will say when you say “hi”? A ngel: Um, I guess maybe “Hello”? Therapist: I would guess that too. But when you are playing Kitty, you can say whatever you think makes sense. And then we can talk it over. OK, are we ready? A ngel: I guess. Therapist: Oops, one more thing. I forgot to take a rating. Hmm, my rating is a 5 out of 10. How about for you? A ngel: For being the lady at the front? A 1. Therapist: All right, here we go . . . (Approaches Angel.) Um, Hi? A ngel: Hello. How are you? Therapist: (Gulps.) Um, fine. How are you? A ngel: Fine. Therapist: And cut. Whew! That was tougher than I thought. My rating did go down, though. I am at a 2 now. How did I do? A ngel: You did pretty good. Therapist: Did I meet my goal? A ngel: Yeah. You said “Hi.” Therapist: Correct. I did! Did it go as we planned? A ngel: Kinda. I guess I said “How are you?” ’cause it felt like I should? Therapist: Right—that was an unexpected bonus. What did I say when you said that?



Conducting Exposures: The Basics  59

A ngel: Well, you said you were OK and asked me how I was doing. Therapist: Yeah. OK. If that happens when you do it, you could do what I did if you want. Now before we go again, anything you think I should do differently? A ngel: Nah. Therapist: Hmm, I noticed that I said “Um, hi” instead of “Hi.” Did you notice that? A ngel: Oh yeah. Therapist: So next time, I will work on saying “Hi” or maybe “Hello.” Which one should I pick? A ngel: “Hello”? Therapist: Good one. Sounds more formal. OK, let’s go again. My rating this time is a 4. Note the therapist’s performance here is not perfect. In fact, it can be useful to be a little clumsy. I encourage therapists I train to lean into coping modeling and away from mastery modeling. Let’s review the idea of coping modeling briefly.

Coping Modeling Modeling is a powerful intervention on its own. Social learning is powerful learning. One thing we know from the literature on modeling is that it can be very useful for clients, especially anxious ones, to observe people doing what is referred to as coping modeling in addition to mastery modeling. By mastery modeling, I mean demonstrating something in exemplary fashion—doing a perfect job. This kind of modeling is useful and helps someone understand what the ideal is for a particular task. Coping modeling is a bit different. Coping modeling is performing the desired behavior successfully and in a way that shows your struggles with it. You may make a mistake or start over or stumble a bit. Steer away from the A+, top score on the AP-level performance and instead show that even if you are distressed and goof up a little, it can still be OK. Although a little mastery modeling can be helpful, especially for anxious kids, showing them that it is OK to muddle through something can be a big relief. Let’s return to breaking down the example. The therapist used coping modeling. Notice, too, Angel made the situation tougher than

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expected. Anticipating and practicing these changes during rehearsal is great preparation, and therefore highly recommended. If the client does not think of the challenges, you will need to do so. Finally, notice that the therapist took a few minutes to shape her behavior for the next trial. She asked for feedback and then offered some of her own. These shaping statements are important and represent gentle ways to present feedback to a client on her performance and to clarify the desired behavior(s). Here are a few other notes on rehearsal. Rehearsal is a great way to gain some insight into how the client perceives the situation and what they expect to happen, especially when the client portrays the target of the exposure. Consider these expectations as guesses or thoughts that are going to be tested out in the actual exposure. For example, Angel may portray the receptionist as rude or dismissive or else she may suggest she will ask a lot of questions. During the task, activate your inner coping model. After the exposure is completed, you can talk things over and observe, “I noticed that the receptionist was not very friendly. She didn’t look up at me or smile. I wonder if Kitty will do that. What do you think you can do if she is like that?” Or “I noticed that the receptionist was friendly enough but she asked me some hard questions. I wonder what questions she will ask you? Let’s prepare for some of those, in case it happens.” Through rehearsal, you gain access to some of the client’s fears about the situation. You also can identify ways to prepare the client’s expectations. One final point on rehearsals: they are important but they are an easy way to get bogged down. Once the client realizes that they won’t have to do actual exposures if they stay and rehearse with you, they may figure out ways to prolong the rehearsals. You may trick yourself into staying in rehearsal mode, since it is still exposure after all and maybe the client is not ready yet. Be wary of this situation. Set yourself an internal goal for rehearsal time. In our example with Angel, the therapist conducted one more rehearsal as Angel and then two more with Angel being the one saying hello. All told, that took about 5 minutes. Anything more than 10 minutes is probably reason for assessing why you are unable to proceed to the exposure task. Of course, this will also depend on how well you have managed time for the session, a critically important task. Bear in mind that although rehearsal does count as exposure, it is much easier than the actual test. So even if you were not wise with your time management and ended up only being able to rehearse, that still is progress. However, if that does happen to you, take it as a lesson and remember to save more time for the exposures in the next session.



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Client’s Guesses on How It Will Go The final step of preparation is to ask the client to guess about how things are going to go. This is where exposure sticks its toe into the cognitive part of the cognitive-behavioral pool. Your goal is to understand what the client anticipates in the exposure situation. What does the client think is going to happen? Rehearsal can help with that, as I noted earlier. Even when you do not rehearse, though, checking in on a client’s guesses for how things will go is an important part of exposure preparation. Note the use of the word guess here. Anticipatory thoughts are simply that: guesses from the client about what will happen. During the preparation phase, you collect them and remain neutral about them because the situation has not unfolded yet; you actually don’t know whether the guesses are accurate. Thus, write down the guesses and let the client know you will check back afterward to see whether or not the guesses were accurate. It is oh-so tempting when collecting guesses to attempt to dissuade the client from having the guesses. Imagine if Angel thought that the receptionist was going to laugh at her or even mock her. Those are guesses. They probably seem unlikely given what you know about your receptionist. However, your job is not to convince Angel that the receptionist will not mock her or laugh at her. Your job is to encourage her to go and find out for herself. And you are doing that because you believe that the receptionist is not a dangerous person. However, you do not want to predict the opposite of what the client is predicting. You do not challenge the prediction. You encourage an experiment with you as a co-investigator. You take the attitude of: Let’s find out what happens. The preparation phase is lengthy. Especially early in exposure and at transition points in the fear ladder (i.e., moving from one topic to another), preparation is a good investment of session time. Preparation is a valued part of exposure just as it is in many other aspects of life, as represented by the aphorisms related to preparing well: “Fail to prepare and prepare to fail”; “Measure twice, cut once”; “Luck is where opportunity meets preparation”; “Spectacular achievement is always preceded by unspectacular preparation.” Because the goal of the first trial in a particular exposure task is success, preparation takes longer early in treatment and becomes shorter as you proceed. Once you have established all of the basic ways things will work and get a few under your belt, the preparation phase becomes a quick run through before the client hits the stage.

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So, rehearsals are done, some guesses are noted, a rating is obtained, and the client seems as ready as they are ever going to be. Time to move on to the actual exposure! Hooray, right? There are some instances in which you may consider using some skills to manage the client’s anxiety before you move to the exposure task. I discuss those circumstances in the next chapter.

The Actual Exposure Though arguably the most potent and important part of the exposure session, this phase is often the briefest. Much depends upon the nature of the task, but most often the preparation and debriefing last longer than the actual task. Despite its brevity, a lot of learning is happening. And your job is to maximize that learning over what amount to quite short periods of time. Let’s walk through the ground rules for the action phase.

Immerse the Client in the Task First, the goal of the task is to immerse the client in the situation or stimulus. As a result, once you have reached the action phase, it is important to encourage the client to approach and engage with the stimulus or situation and not with you. Once you have completed a few exposures with a client, it gets easier. However, in the beginning, there can be a tendency on both of your parts to engage in inadvertent distraction and avoidance. As an example, let’s turn again to Angel. She is prepared to introduce herself to the receptionist. Now imagine you are several feet away from the receptionist and have taken the final rating from her prior to her approach to the receptionist. At this point, your job is to ensure that Angel completes the task. She already has all of the information she needs to do so. She knows what the deliverables are for the situation. Thus, any questions she may have only serve the twin forces of distraction and avoidance. In the beginning, for the first exposure or two, it is acceptable to provide very quick and brief reassurance and clarification. However, the general rule is to say to the client, “I know you can do this. I know it’s hard. Good luck. We’ll talk afterward.” Your job is not to ensure that the client feels 100% good about the situation. In fact, the goal is for the Angel to feel uncomfortable. It is not real exposure without some degree of discomfort. Your job, and the first ground rule,



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is to encourage the client to engage with the feared stimulus despite the discomfort.

Be a Distant Observer Once the client has begun to approach and engage with the situation or stimulus, you move to ground rule #2: Be a distant observer. Thus, you must ignore Angel’s efforts to engage with you until she completes the task. During preparation, you should let Angel know you will ignore her during some exposures and you should tell her why. Let her know you will be there as a silent and supportive observer. You may need to explain how avoidance works to make anxiety worse. Even if she makes meaningful eye contact and looks scared, a quick thumbs-up followed by an eye aversion will send all the support you should give. Because the point of an exposure task is to ensure that the client learns from interacting with the stimulus or situation, that learning will be enhanced if done independently. In short, the client learns that they can approach and engage with the stimulus on their own.

Exceptions There are exceptions to the second rule. The first of these is an obvious one. If the client is in some danger, then you immediately intervene. By “danger,” I mean, for example, that the receptionist begins to yell violently at Angel or threatens her in some way. However, if the receptionist was somewhat mocking or rude to Angel, that would not be considered danger. You would definitely need to debrief carefully after the exposure and help Angel think through what happened. (And you will need to talk with your receptionist as well.) But rudeness alone would not be grounds for stopping the exposure task. However, you may choose a different task after a single trial with a rude receptionist. The second exception is somewhat less obvious and much more of a judgment call. There can be times when the client and the therapist, in their efforts to identify an appropriate exposure task for the session, have made a mistake. The item on the fear ladder may have initially seemed appropriate but in real time the stimulus is much more anxietyprovoking than the client and the had therapist anticipated. Here, I must emphasize the words much more. It is common for a stimulus to evoke more anxiety than was anticipated based on the initial anxiety rating on the fear ladder. As was discussed already, it can be difficult to judge how anxious we will be in situations when we are presented with them in an

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abstract way. So, it is never surprising when the client is more anxious than anticipated in the face of an exposure task. What I mean by mistake is that a line has been crossed and the client starts operating entirely within the fight-or-flight system. I explain this line to trainees as the difference between what some have called the learning zone and the danger zone. You may be familiar with Lev Vygotsky’s zone of proximal development, where three concentric circles represent what someone knows, what they can learn with assistance, and what cannot be learned. The concept was adapted by Senninger (2000) and others to include a comfort zone, representing what you could do without fear, a learning (or stretch) zone, which was tough but manageable, and a danger (or panic) zone, representing a task or situation that created unmanageable levels of anxiety. With gradual exposure, you are aiming to have the client firmly in the learning zone—a place where their anxiety is at a moderate level—uncomfortable but not terrifying. Even at its most uncomfortable point, the learning zone is a good place for a client to be, even if they disagree. However, you do not want the client to tread into the danger zone, where they are not learning. A therapist should intervene and interact with the client during the exposure task. Knowing when a client is in the learning versus the danger zone can sometimes be determined from the ratings. Unfortunately, though, it is not generally that simple. Knowing whether the client is in the learning versus the danger zone will also involve your judgment as a therapist. That brings us into the nuance of doing exposure, where it is not possible to give a firm answer to the question “How will I know?” Let me offer a few examples to help you begin to see how you will develop your judgment. It is common in exposure for a child to cry. Crying is not by itself a reason to stop exposure, though it is a supremely uncomfortable situation for the client and the therapist. You, a grown adult, are standing there making a child do something that upsets them so much that they are crying. Not exactly how you saw things going when you were in your grad program, I bet. So, crying alone is not enough to abort the mission. In fact, crying can be, in some ways, a good sign: the client is obviously anxious and perhaps hoping that by crying, they will be allowed to avoid. You can bet good money that others in their environment have let them off the hook for crying. But you, intrepid therapist, remember the dangers of negative reinforcement and hang in there. But here’s the rub. You have to use your intuition to gauge whether the crying is “They can do it” crying or “Nope, that is someone who is too upset to proceed.” The first time a client cried in exposure when I was therapist was



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one of my first exposures. Leila, the 9-year-old client and I had only done one exposure before and it was an imaginal exposure. Here we were then, with her crying in front of the elevator we had agreed she would ride with me down to the ground floor. Other people were walking by. It was mortifying. Yet I remembered that exposure could lead to this sort of behavior. I let her know gently that I was here and that we would get aboard the elevator. Then, I waited. It did not take long (though it felt like an eternity) for her crying to ease off. In a few minutes, we were riding the elevator. In that situation, I judged that she was crying to avoid but that she could handle the situation. My evidence was this: (1) She had taken the elevator to the appointment with her parent, (2) I knew from her assessment that she cried whenever she was afraid, (3) the elevator was low on her fear ladder, and (4) although she was crying, she did not appear overly distressed to me (see Chapter 8 for further discussion of Leila). Other clients will not cry but will seem upset. They may tremble or hesitate. They may verbally say they cannot do the task. They may even freeze up. Again, this is par-for-the-course in treating anxiety. You have to prepare yourself to handle distress from the client. As with crying, you have to gauge whether these other anxiety-related behaviors necessitate a pause. In training new therapists, I urge them to hold out unless they are certain the client cannot handle the distress without some support. It is almost always OK, though, to label the distress. “This is hard, but I know that you can do it.” Remind yourself that intervening is avoidance. Only intervene if you can think of no other way. If forced to define the line between whether to intervene and not, I would say that you will interact with a client during an exposure if you believe that the situation you have chosen as an exposure task exceeds yours and the client’s expectations with regard to the goal established at the start of the session. The basic rule is to intervene only if the situation exceeds the anticipated anxiety produced by a wide margin. Many of the later chapters in this book focus on the issue of knowing “when to hold them and when to fold them,” each doing so for specific problem areas. The third and final exception of talking to the client during exposure concerns times when there are real decisions to make that require your input. An example might be if you are working with a client who is fearful to interact with customer service people in a store. Imagine you have sent Angel over to an employee to inquire about the location of a particular item. She approaches the store employee, asks where the item is, and then the employee offers to escort her to the item. This would be a time for you to intervene, even if the client doesn’t request it, to

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determine if the client will proceed with the employee. The third exception most often occurs when there are unanticipated developments; these tend to arise more frequently in the context of social anxiety exposures (see Chapter 7).

Take Ratings With the exceptions out of the way, you are ready to move on to the third step of the action phase of exposure: taking ratings during exposure. The step does not always occur and is not always recommended. (For reasons I just reviewed, talking during exposure takes the client out of the exposure.) However, there are many instances in which you will need to take ratings during exposure. To intervene in the middle of an exposure, even to request a simple anxiety rating, is an interruption and a distraction. Thus, it is not ideal. A few examples will help clarify when these intermediate ratings are needed. First, anxiety ratings within a trial are common when using exposure for specific phobia. Whether the feared stimulus is a spider, a dog, or the sound of storms, the exposure task itself often involves a prolonged experience with a particular stimulus. During that prolonged exposure, you will gather ratings periodically (initially every 15–30 seconds or so; later, every minute or so). These ratings help to track your way through the exposure task, like the GPS I mentioned earlier. Ideally, these ratings will be going down over time, though that is not always the case. Another time you might use anxiety ratings within a trial would be in some social performance anxiety-related exposure tasks, such as giving speeches or oral presentations. I often collect ratings in the middle to help me understand how things are going. For both examples, these intermediate ratings can help the client learn that their anxiety is falling the longer they stay in the situation. Taking ratings during an exposure task can also help you understand what processes might be prolonging or increasing anxiety. If a client’s anxiety is increasing in the early part of the exposure, you may hypothesize that the client is engaged in some cognitive activity that might be exacerbating the anxiety. The exposure task phase is over once the client has completed whatever the assigned task was. So, for example, if the task was a simple one, such as Angel saying “Hello” to the receptionist, once she has said hello, the action phase is over. Other tasks take longer. It might be, for example, that the client must deliver a 2-minute speech or presentation. Or the client has to engage in a longer conversation with someone. There are more nebulous tasks that have less obvious endpoints. An example might be exposure to a phobic stimulus, such as a spider. One fear ladder



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item may be to watch a video of a live spider walk around. One could terminate the exposure task when the video ends. Extremely short videos are not ideal, though, as the client may not experience any reduction of anxiety during the task. With video, a good rule of thumb is aim for at least 1 minute and to consider using a looped video. A video stimulus has an obvious termination point. Some stimuli do not. Imagine someone who is afraid of heights. You might have the person look over the edge of a building. That stimulus does not have a natural termination point. In such an instance, the goal is for the client to be engaged with the stimulus long enough for the opportunity of anxiety reduction and habituation to occur. Similar situations include being separated from a caregiver or reflecting on worries. These stimuli do not have clear timelines. Remember back to Chapter 1 when I discussed within-trial and between-trial habituation. Here, I am talking about within-trial habituation. The client ought to remain in the situation long enough to begin to experience anxiety reduction. Thus, in these more nebulous situations, the length of the exposure task is basically as long as it takes for the anxiety rating to begin to decrease. Note that in the beginning, it need not be so long as to allow the client’s anxiety rating to reduce to 0. It may be that the reduction of a few points is sufficient in an early trial period because that may be sufficient to demonstrate that exposure is having the intended effect. Bear in mind that the goal over the long term is for the client to experience both within-trial and between-trial habituation. That is, you want the rating to go down during each trial, but you also want the client to have the opportunity to see that the more times they do the task, the lower their initial anxiety ratings are and the more quickly the anxiety ratings go down. So, for exposure stimuli without natural termination points, you maintain the client in the situation until they begin to show some within-trial habituation. Overall, though, each instance of the action phase rarely lasts more than 5 minutes. The key is for you to repeat the action phase over and over and over again, so often that eventually it gets boring. At least, that is the goal. Before you hit the repeat button, though, you have to debrief the exposure.

Debrief Praise the Client The debrief phase almost always starts with praise from the therapist, as effusive as you can muster that fits with your sense of what the client will like. Exclaim about how well the client did in engaging with the

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feared stimulus. It is important to tailor the praise of the client to their preferences. Some clients do not enjoy overly enthusiastic praise, preferring subdued praise like a fist bump or big smile and “Good job saying hi to Kitty!” without a lot of extra exclamation points. Most clients, however, benefit from an enthusiastic response. And even for those who prefer a more subdued response, I tend to recommend a slightly more upbeat response than you think the client would prefer. Your goal is to be responsive to the client’s preference and also to make clear how excellent and important it is that the client did something they were afraid to do. In short, you give as much praise as you think the client will stand. Remember too to give praise that is specific and labeled. Make specific comments about what the client did that was great. At a minimum, you can almost always say, “Wow! That was a tough situation and you handled it well. You stayed in the situation even though you were anxious. I am impressed that you did it.” Focusing the praise on the coping and approaching behaviors reinforces the actions you seek more of from the client in these anxiety-provoking situations.

Take Ratings Once you have praised the client, you then immediately take a rating. You might even take the rating before or during your praising of the client. You want to know the final rating quickly. Then, you ask the client for qualitative feedback about how they thought it went.

Ask How the Client Coped What did they think worked? What was the hardest part? That was impressive—how did they cope? The client will have just completed a task that had heretofore made them so anxious that they avoided it. Now, they have completed the task and you can get firsthand input from them about how they did it. Note the emphasis on how the client coped. Emphasizing the client’s agency is an important step because a goal during the debriefing is to bolster the client’s sense of self-efficacy by pointing out the truth: the client coped! They completed something that was difficult for them, an accomplishment worthy of some attention. During this discussion, your own observations are not only germane but often necessary. You can note what you saw the client do. For example, if Angel was able to ask the receptionist how she was doing when she did the greeting, you can exclaim, “Wow!—You went a whole extra mile there by asking her how she was. How did you think of that? That was excellent!”



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Review the Client’s Guesses Remind the client about their guesses about what would happen and run through them like a scorecard. Tone here is important. In general, avoid the “I told you so” tone and instead go with the “I am curious, since I did not know how this would turn out either” tone. Remember that the two of you are co-investigators. If any guesses were not accurate, you add those data to your database. Do the same with accurate guesses. An important goal with cognitive work is not to emphasize that the client was wrong about their guess. Instead, you help the client integrate the new data into their thinking about the stimulus. The goal is a corrective learning experience. Part of that correction is the behavioral and emotional one that happens during the action phase. The debriefing phase assists with these two, too. And it adds in these important cognitive learning experiences as well. A quick example from Angel’s case can bring this home. Therapist: Let’s look back on your guesses for how it would go. I am putting on my scientist hat. Let’s look at the data. Hmm. You guessed that she would be busy. Was she busy? A ngel: Well, maybe. She was doing stuff. Therapist: OK, so ”maybe” on that one. You also guessed that she would be a bit mean. What was it you said, she would be “grumpy.” What do you think about that one? A ngel: Not really. She was kinda nice actually. Therapist: Let me scratch my scientist beard here. What is the evidence that she was nice? A ngel: She smiled, I guess. And her voice was not grumpy. Therapist: Good examples. I will add that to the evidence here. So “not grumpy” this time. And the last guess was that she would ask you to leave right away. Did she? A ngel: No. She actually asked me about my t-shirt. Therapist: OK, fellow scientist—we have evidence against the idea that she would ask you to leave right away.

Prepare for the Next Trial As the discussion of how things went proceeds, you transition into preparing for the next exposure trial. Remember: you are never doing an exposure task a single time. Instead, the goal is always doing them in a series of trials. Thus, the debriefing leads seamlessly into preparation.

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Part of that transition is talking about how the last trial went and how to use that information to guide the preparation for the next one. This involves both focusing on what the client did that went well last time as well some gentle feedback on how things might go a bit better next time. As an example, let’s consider Angel again. Imagine that in the first trial things went well. Angel approached the receptionist and said, “Hi,” and then turned and came back to you. Here is what might happen next. Therapist: Excellent job! You went right up, said Hi. You looked pretty confident. Great job! A ngel: Um, thanks, I guess. Therapist: How did that feel? What is your rating? A ngel: Oh—um, like a 2. That was kinda easy. Therapist: Kinda easy. I like to hear that. Why did it go well, do you think? A ngel: I mean, she is really nice. Therapist: What things did you do that made it go so well? A ngel: I am not sure. I just did it. Therapist: That is pretty important. Sometimes anxiety makes us so scared we don’t want to do things. You were brave and did it anyway. OK—you know what happens next? A ngel: Repeat. Therapist: Right—hit that repeat button. What is your rating now? A ngel: Oh, saying Hi to her again? Like a 2. Therapist: OK—off you go. Now, let’s say that after the next trial, you notice that whereas Angel is doing a great job of saying, “Hi,” she is not making eye contact. Here is how the therapist might handle that issue. Therapist: You are cruising now—what was your rating that time? A ngel: Um, that was kinda easy. Like a 1. Therapist: Wow—great—that came down pretty fast. I had an idea for the next one. We can make it a bit tougher by adding a wrinkle. Let me show you what I am thinking. Pretend like you are Kitty and I will be you. OK—here I come. (Walks over to Angel, looking down.) Hi.



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A ngel: Um, hi. Therapist: OK. Let’s call that level 1. You got that one down! Now here is level 2. (Walks away a few feet.) I am still you and you are Kitty. Ready? (Walks over to Angel, making better eye contact.) Hi. A ngel: Hi. Therapist: What was the difference? A ngel: I am not sure. Therapist: Did my words change? A ngel: No. Therapist: Did my volume change? A ngel: Not really. Therapist: How about my body language? What were the differences there? A ngel: Um, well I guess you were looking at me the second time. Therapist: Right. Let’s call that level 2. Let’s try the next one with you and Kitty at level 2. What is your rating for that? A ngel: A 2, I guess. Therapist: OK, let’s do the next one. The debriefing phase shifts directly back to the preparation and action phases, with the former becoming more abbreviated as you progress. See? Exposure is deceptively simple. Speaking of progress, let’s shift gears and see how you will know how things are going in treatment using exposure.

Measuring Progress Recall that when the anxiety level at the end of a trial is lower than at the beginning, the client has experienced within-trial habituation. In short, the client’s anxiety level has decreased during the event. Figures 4.1–4.3 are the pre–post scores for the first, third, and fourth trials for Angel, each demonstrating within-trial habituation. In Figure 4.4 is Angel’s initial ratings of saying hello to the receptionist over six trials. Note that the initial rating stayed at a 5 for three trials before quickly dropping to a 3 and then 1 for the last two trials. Angel’s data gives us good evidence for between-trial habituation, the

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Anxiety rating

5 4 3 2 1 0 Initial Anxiety

End Anxiety

FIGURE 4.1.  Angel’s ratings, trial 1.

other important intermediate goal. Not only does anxiety go down if the client approaches and engages with the stimulus. Her anxiety gets lower every single time she does it.

Troubleshooting Habituation A few troubleshooting comments on habituation are warranted here before I close the chapter. First, within-trial habituation is often the

6

Anxiety rating

5 4 3 2 1 0 Initial Anxiety

End Anxiety

FIGURE 4.2.  Angel’s ratings, trial 3.



Conducting Exposures: The Basics  73 6

Anxiety rating

5 4 3 2 1 0 Initial Anxiety

End Anxiety

FIGURE 4.3.  Angel’s ratings, trial 4.

most challenging of the two to achieve. Sometimes, a client may feel the same level of anxiety throughout an exposure, especially one of brief duration. Early exposures often involve the white-knuckle approach of coping that you can shape later; I will discuss this issue in subsequent chapters. A key, especially early, is not so much the achievement of within-trial habituation as the accomplishment of multiple trials. If the client is engaging with the feared stimulus over multiple trials, then

6

Anxiety rating

5 4 3 2 1 0

1      2      3      4      5      6 Trials

FIGURE 4.4.  Angel’s ratings across six trials.

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you are on the right road. If you are not seeing within-trial habituation, fear not. With that said, you can and should look for within-trial habituation. And your look needs to go beyond the ratings provided by the client. Bear in mind that most (all?) people are not 100% accurate in reporting how they feel, even if they are trying to do so. There are myriad reasons why a person might report a fear rating that is not 100% consistent with how they really feel. As I discussed in Chapter 3 on assessment and monitoring, once you have ensured that the client understands the rating scale, you take their ratings at face value and you gather additional data. As trained and astute observers of others, therapists are encouraged to use their skills to watch for behavioral indicators of reduced anxiety in the client as a trial (or set of trials) proceeds. Have the client’s shoulders relaxed? Has their posture loosened? Have they become more verbal? Have they opened their body toward the stimulus (vs. being closed off)? Have they smiled at the end of any of the trials or seemed pleased? As mentioned earlier, all of these and other observational forms of data can and should be remarked on by the therapist to draw the client’s attention to them. Your commentary to the client can be helpful in their seeing and feeling the changes that are apparent to you (but not to them). However, there is nothing like working with a client who is a good candidate for exposure and seeing it work, seeing how the client’s world opens up, and they learn that they can cope. They can approach and engage. It is a rewarding experience for the client and the therapist. It is worth making one last point here, one that will be implied in what follows. The goal of exposure therapy is ostensibly to help clients create a new learning history with stimuli that heretofore they avoided or endured with extreme distress. To accomplish that goal, exposure therapy has emphasized the learning theory concept of habituation. However, having a corrective learning experience with a stimulus is likely to be best if it is a full body-and-mind experience. That means that optimally, we aim to have the client experience what Himle (2015) refers to as the passive experience of habituation, along with new experiential learning across emotional, cognitive, and behavioral channels to generate a new relationship with the stimulus (cf. Garcia, 2017). Thus, habituation is important to exposure, but exposure is bigger than habituation. This chapter has sought to present a general overview of how to do exposure therapy. What it looks like in the room. In the next chapter, I will grapple with the tough question of how and when to use coping skills in exposure treatment. After that chapter, I will dive back into



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exposure in more specific detail, doing so by problem area. I will examine specific fear ladders for each problem area and talk through some of the common challenges for each. The basic principles established in this chapter represent the base competency you will need. The proceeding chapters add specialization to help you guide your anxious clients as they approach and learn to develop new and more adaptive relationships with their fears with courage.

CHAPTER 5

Exposure and Coping Skills

I

have thus far tried to offer a compelling case for exposure as a standalone or primary intervention in treating a variety of anxiety-related problems. As deceptively simple and impressively effective as exposure is, it is not the cure for all ills. Many readers are already familiar with the vast literature on coping skills approaches that often accompany exposure interventions in CBT programs. There are many cases in which a focus on coping skills in addition to exposure will be an easily defensible plan. As noted at the outset, the goal here is not to make the case that exposure and exposure alone is the answer. Instead, the goal is to present a deep dive into the nuts and bolts of the intervention because exposure is highly potent for treating anxiety yet it is often avoided in favor of coping skills. This chapter balances things out with a discussion of ways you can integrate coping skills training into exposurebased treatments. I start by discussing some dos and probably don’ts in terms of the timing of these skills interventions. I then identify and briefly describe three of the more common coping skills interventions useful in treating anxiety: (1) relaxation, (2) cognitive skills, and (3) problem solving. Other common skills training components in CBT programs for anxiety include social skills training, self-reward skills, and assertiveness training. Recently, mindfulness approaches have also become common. There are numerous books that cover all of these skills approaches; interested readers are referred to these resources (e.g., Chorpita, 2007; Friedberg & McClure, 2015; Kendall, 2018; Manassis, 2012). 76



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When to Use Skills Interventions (and When Probably Not To) CBT programs generally include ample focus on coping skills interventions. Based on this fact, some therapists (and clients) express the notion that coping skills must precede exposure or else the client will be unable to cope. The astute reader will recall, however, that there is good evidence from many studies that exposure as a standalone intervention works well in treating child anxiety. Clearly, coping skills need not precede exposure. I am making a distinction between focused time spent on teaching a coping skill like cognitive or relaxation and teaching the skill on the fly during exposure. I like to ask folks to recall how they have approached a scary situation in their own life—either with themselves or their kids. A simple example may help. Imagine your daughter, age 7, wants an ice cream cone. She is a bit shy to order from the vendor. Let’s see how this plays out in two different scenarios: Parent: What flavor do you want today? Daughter: Oreo. Parent: Yum! How do we order? Daughter: Um, say “Oreo.” Parent: Good. Anything else? Like cone or cup? Daughter: Cone. Parent: Sounds good. Let’s both take a deep breath. Here we go. Ice Cream Vendor: What would you like? Daughter: Oreo, please. Ice Cream Vendor: Cone or cup? Daughter: Cone, please. Ice Cream Vendor: (scooping) Here you go. In the first scenario, we see a parent unwittingly using the basic exposure approach. Rehearse. Add a little coping skill. And go. Let’s see this a bit differently. Parent: You are going to order for yourself today. What flavor do you want? Daughter: Oreo.

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Parent: You look a little scared. Let’s go back to the car so I can teach you how to relax. Daughter: OK. [15 minutes later] Ice Cream Vendor: What would you like? Daughter: Oreo, please. Ice Cream Vendor: Cone or cup? Daughter: Cone, please. Ice Cream Vendor: (scooping) Here you go. In scenario two, a parent takes extra time to teach a skill in more depth. Both scenarios end up with a scoop of Oreo ice cream. And notice that in both scenarios coping skills are taught. In the end, it is not as if exposure alone means the client learns no coping skills. So, why would you choose scenario two? Consistent with my overall approach, I offer a few ideas but no firm answers. Each situation must be considered on its own. However, what follows are several situations in which using coping skills may be useful and a few others when I recommend you think twice before diving into in-depth coping skills training.

Social Skills Deficit: Probably Yes Some clients with social anxiety have still managed to develop reasonable social skills. They have good interactions with family and a few friends and their social skills are adequate enough to mean that as you proceed through a fear ladder, they can sharpen their skills without needing in-depth work. That is, they can improve their social skills through exposure tasks. Other clients, though, will have more severe social skills deficits. They do not have many interactions with family or a few friends and their skills are so limited that your assessment is that exposure may make things worse (e.g., social rejection, increased avoidance). In such cases, diverting away from exposure to social skills training can prove fruitful. I discuss this topic in some detail in Chapter 7. And notice that in this case, the skills training will involve exposure to some extent as you will be rehearsing social situations with the client to strengthen their social skills. There are some excellent social skills training books out there, including Bierman et al. (2017), Frankel (1996), and Laugeson and Frankel (2010). And for youth with social anxiety who also have



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higher-functioning autism, consider the excellent book by Susan White (White, 2013).

Expert Worrier: Often Yes Clients with generalized anxiety disorder (GAD), those who worry a lot, are often challenging clients because addressing their concerns can feel like playing the Whack-a-Mole game. I cover strategies to address worries via exposure in Chapter 9. I note there, and here, that it is often helpful with a client who worries to focus some time on building cognitive skills prior to engaging in exposure tasks. Whereas the target of exposure for many other fears is an environmental event or situation, for worriers, the target is often between the ears. Worriers are focused on possible futures and often have trouble with exposure unless they have spent some time in the cognitive gym, exercising their discernment about their own thoughts. In our clinic, we do not always focus on cognitive skills with GAD cases, but almost always.

Extreme Physiological Anxiety: Probably Yes I had a professor in graduate school who liked to demonstrate physiological reactivity differences by asking the students to measure their heart rates. He would then unexpectedly slam a large book onto his desk, resulting in a loud and surprising sound. He asked us to continue monitoring our heart rates. He would then continue with the lecture, asking us to continue monitoring. His point was that some people’s heart rates barely show a jump with such a surprise, whereas others show a large jump. And there was another notable difference he highlighted: some folks return to baseline quickly whereas others do so more slowly. For some people, that heart can stay pounding for a long while. Some of your anxious clients will have a high degree of physiological reactivity. They may be prone to startle and experience large shifts in their physiology in response to the environment. They may have a resting anxiety rate higher than others. For some of these kind of clients, it can be helpful to teach relaxation and other emotion regulation skills in advance of exposure so that they learn that they do indeed have some ability to sway their own physiology. You may choose this route in particular with clients whose resting anxiety rating is so high that even items low on the fear ladder produce a near panic attack. Better-developed relaxation and other emotion regulation strategies can help the client dial things back

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just enough to approach the fear ladder items and remain in the learning zone (and not fall into the danger zone).

Client Lacks Confidence: Probably Not Some clients may exude an air of no confidence. They do not seem to believe they can do any of the items on the fear ladder. In many such cases, doing some morale-boosting skills training is avoidance of the fear ladder items. The client learns that by exuding low confidence, they get you to back down from exposure and move to the much easier skills training that often involves one-on-one interaction with you, a super nice therapist, and sometimes even fun games. Who wouldn’t rather hang out with you than do scary things? Thus, in these cases, it can be helpful to reflect on how much confidence the client will have once they complete a few exposure tasks.

Therapist Lacks Confidence: Definitely Not Some therapists are wary about using exposure. I talked about this in earlier chapters: fears of traumatizing clients, fears of going too fast. If you are trained in exposure and/or receiving training and supervision from someone adept in exposure, then your own lack of confidence is not an adequate reason to use coping skills training instead of exposure. You may benefit from your own fear ladder in using exposure and from processing your concerns with your supervisor. However, please do not let your own fears get in the way of delivering the best treatment to your client. In short, coping skills training is best saved for clients for whom you have assessed a clear skills deficit, either identified initially or assessed during the course of treatment. In other cases, it is best to work the fear ladder, while engaging in exposure, and teach some copings skills in vivo.

Skills Training Interventions CBT programs generally include ample focus on coping skills interventions across a wide spectrum. Because this book focuses on exposure alone, I will not review all of the different types of skills found in CBT programs. Instead, I will focus on three of the most common ones found in them: relaxation, cognitive skills, and problem solving.



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Relaxation As noted earlier in this book, exposure was originally developed to be accompanied with relaxation approaches; hence, the pairing of them has a long history. Further, teaching an anxious person how to use relaxation skills has a certain degree of logic. The most compelling rationale for relaxation is grounded in the nervous system. Recall that we have a central nervous system (CNS) and a peripheral nervous system. We tend to focus a lot on the former, the CNS, because of its superstar component: our big and amazing cerebral cortex. It is true that our CNS plays a critical role in our emotions, thoughts, and behaviors. As a result, it makes sense that the CNS gets so much attention. The peripheral nervous system, though, is a key player too. Its system has two divisions: somatic and autonomic. The somatic system consists basically of the nerves that carry information from our body to our spinal cord and brain (and back out again). Now that you think about it, sounds pretty important, right? The autonomic nervous system (ANS) is in charge of our involuntary responses and helps to keep our bodies in relative homeostasis. The ANS accomplishes that goal through two parallel systems: the sympathetic and parasympathetic nervous systems. The sympathetic nervous system is essentially the fight-or-flight system; it prepares us for immediate action in life-threatening situations. I have already made the connection of the sympathetic nervous system to anxiety; the system is our alarm system, allowing us to survive dangerous situations through evasive or aggressive actions defending ourselves. The sympathetic nervous system involves involuntary behaviors and is not generally under direct and conscious control of the CNS and that big brain of ours. That is one reason why, as I have noted, anxiety problems develop in the first place. Sometimes the alarm goes off and it is not an emergency. Even so, the alarm is loud, insistent, and terrifying. And not easily turned off. Also, in the ANS is the parasympathetic nervous system, sometimes referred to as rest-and-digest or, to the chuckles of teens when I tell them, feed-and-breed. The parasympathetic system is a largely opposing one for the sympathetic system, involved in regulating bodily activities that generally occur when a person is at rest such as digesting a nice meal. The system is activated when the organism believes it is in a safe place and able to let its guard down. As a result, the parasympathetic system is the star of the present section. With relaxation strategies, you

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aim to activate that system and move the organism into a state of perceived safety. There are many pathways to relaxation studied in the literature. In fact, relaxation as an intervention has a long history and has been tested and found effective as a standalone treatment for anxiety and depression in children and adolescents in multiple studies. I cover a few of the more common ways that relaxation has been implemented for anxiety next.

Breathing Retraining The first relaxation strategy is arguably the most simple and basic: breathing retraining. Its focus is on bringing the largely unconscious process of breathing under conscious control, with the goal of making the breath become slow and measured as a signal to the body that the person is safe and all is well. You can find numerous helpful images and GIFs on the Internet to serve as the model for breathing retraining. There are also numerous apps available on smartphones. A trick here is that the amount of time to use for inhalation and exhalation is not standard across all humans, and so you will have to feel your way into the pattern that works best for your client. The overall goal is to slow and deepen the breath. A reasonable starting point can be to have inhalation last 3 seconds and to have the exhalation match that time. When I teach breathing retraining, I often start by emphasizing that the lungs are large and can hold a lot of air. The average breath is about 0.5 liters of air, whereas the capacity of the lungs is about 10 times that (between 4 and 6 liters). That is two or three 2-liter bottles of soda! I liken our typical breathing approach to using a really thin straw to drink a thick milkshake when we could be using a soup spoon. I further emphasize the importance of breathing to our bodies functioning. What does breathing do for us? It brings oxygen into our bodies and bloodstreams and removes carbon dioxide. The more oxygen we take in, the better we function across the board. And that includes managing our anxiety. If we are breathing slowly and deeply, we have plenty of oxygen circulating and our bodies are operating well. Breathing retraining has wide benefits, as noted, and also is a highly adaptable strategy, as it can be used in nearly any situation. Professional basketball players use the strategy as they approach the free throw line. Performers use the strategy right before they walk onto the stage. Students can use it right before a test. And for the most part, the skill is one



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that will be invisible to those observing. Even just a minute or two of slow and deep breaths can make a big difference in how we feel.

Progressive Muscle Relaxation More complex relaxation exercises have been tested and developed. One of the most common is called progressive muscle relaxation (PMR). With PMR, the goal is to help the client become aware of how tension may be held in different areas of the body through a series of tensing and relaxing exercises. Through the exercise, the client learns to tell the difference between the tense and relaxed states. States of tension often occur in our bodies without our direct knowledge. We can suddenly find ourselves with our hands clenched or our shoulders pressed tightly against our ears. PMR helps to sensitize the client to these different sensations with the end goal being to notice when the tense states are occurring in vivo so that they can be countered with the relaxed state. With younger children, the robot–ragdoll exercise can be a helpful way to orient the client. In this exercise, the client alternates between acting like a stiffly moving robot to moving like a floppy and relaxed ragdoll. There are also scripts to use in engaging in PMR, including some that use more child-like imagery like squeezing lemons in our hands or preparing for a baby elephant to step on our stomachs. Those for older children are more matter-of-fact, moving around the body. You can find numerous examples of these scripts on the Internet, including 10 free versions at https://www.practicewise.com/portals/0/MATCH_public/ relax.html, including versions in English, Spanish, and German.

Guided Imagery A final variant of relaxation to mention is guided imagery. Here, the client is led through an exercise designed to have them imagining themselves in a safe and relaxing place. The therapist (or a recording) generally starts the exercise with guided deep breathing, moving into a vivid and multisensory description of a scene that the client finds relaxing and safe. The scene can be highly variable, with some children preferring quiet home scenes, others beach scenes, still others forest scenes. Obviously, you would work with the client to build a scene that is optimal for them. Your task is to create a compelling and multisensory experience for the client. A brief example is included here for Cole, a 13-year-old male client who was having trouble sleeping due to anxiety. He identified the beach as his favorite relaxing place.

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Therapist: OK, first let’s get comfortable. Is it OK if I dim the lights a bit? Cole: Sure. Therapist: What is your anxiety rating to start today? Cole: The 0–10 thing? Um, a 6. That test I was telling you about was very stressful. Therapist: OK. Let’s see if this exercise can help a little with that stress. So lean back in your chair there. If you feel comfortable doing so, close your eyes. I will close mine too. Let’s start with the breathing exercise we learned last time. We breathe in slowly for a count of three and then we breathe out slowly for a count of three. In . . . Out . . . In . . . Out . . . In . . . Out. . . . Good job! Now I want you to create in your mind a picture of a beach, just like the beach you told me about at Ocean City. Imagine you are sitting on one of those chairs that is close to the ground and lets you stretch your legs way out. (Pauses.) And it is one of those chairs that leans back too, so you are reclining back. You hear the waves gently crashing against the shore. There are gulls crying out and the sound of the wind rustling in the grasses behind you. (Pauses.) The sun feels warm on your face and legs. Your feet are sinking into the warm sand and you feel the breeze move across your head and neck. (Pauses.) You can smell the salty air from the sea and you can smell French fries from nearby where someone must have gotten them from the boardwalk. (Pauses.) You can almost taste the salt because your body is still wet from having swam in the ocean just a few minutes ago. The wet saltiness is drying off you from the warm sun but your body still feels cool but not cold from the water. (Pauses.) Before we continue, just check in on your breathing. Let’s do a couple of slow deep breaths. In . . . Out . . . In . . . Out . . . In . . . Out. . . . The exercise usually lasts about 5 minutes, although with some clients you may choose to go much longer. At the end of the exercise, remember to take a rating and debrief on what worked best and what made it tough to relax. With the guided imagery and PMR exercises, a therapist can create an audio recording for the client to take home and use for homework. Although you can find a number of versions on the Internet, you may find it useful to create the recording yourself, as the client may value hearing a familiar voice when engaging with the exercise.



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Relaxation can take many other forms, including more active forms such as yoga or walking relaxation. The form used is likely not as important as the principle being taught: clients can take some actions that will help them calm their body when anxious or upset.

Mindfulness Mindfulness is a skill that has some overlap with relaxation. The practice of mindfulness is ancient, dating back at least to the first sermon of Buddha more than 2,500 years ago. The seventh element of the Noble Eightfold Path, the practice of mindfulness is central to Buddhism and is one of the keys to attaining enlightenment. A basic definition of mindfulness is that it focuses on attention to the present moment and that the present moment contains external sensory events as well as internal events. A simple way to think of the practice of mindfulness, then, is that it is attending to the events of the present moment only and remaining focused solely on the present moment. Mindfulness typically also involves nonjudgmental attention, that is, to experience the present moment without judging it or trying to alter it. Evidence is emerging about the usefulness of the practice for a variety of problems areas with adults and adolescents. There are a number of excellent resources available to learn more about mindfulness and its use in mental health treatment (e.g., Greco & Hayes, 2008; Orsillo & Roemer, 2011).

Cognitive Skills The emphasis of this book is on the “B” part of CBT and one of the big-B ingredients in the pantry is exposure. As a result, I have given cognitive ingredients much less attention. However, cognitive work is almost always part of exposure therapy. Before I explain that statement, let me provide some brief background to clarify how I think about cognitive approaches. One of the myths that I hear about cognitive therapy is that it is about teaching kids to think positive. When I am doing cognitive work, I am not in the business of teaching clients to think happy thoughts. Instead, I seek to teach clients to develop a different way of relating to their own thoughts, to become better consumers of their thoughts. I know that this is a subtle point. It is not easily grasped even by bright adult clients (nor by some therapists, either). The brief take-home is that when you do cognitive restructuring, you are not there as a thought fixer, you are not selling the idea that positive thoughts are better or

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more realistic, and you are not trying to help clients see that their thinking is wrong. So what are you doing? As noted, your work is to help clients become better consumers of their own thoughts—to learn how to identify them, to see them as thoughts and guesses (not as facts), and to understand that they can have some agency with their thoughts. They can sprinkle new ones into the mix, noting how their thoughts influence their feelings and actions. And they can interrogate their thoughts, weigh evidence to determine if a thought has a basis in fact or is an exaggeration. To accomplish this goal, I offer three pieces of advice. First, join the “impartiality squad.” That means that you should help clients to observe and discuss their thoughts without taking a side in the conversation. You are there to help them sift through thoughts, not to impose your own perspective on clients and their thoughts. Second, remember the old adage about giving a person a fish versus teaching the person how to fish. It takes longer to help a client learn how to generate different and novel thoughts to add to the mix. Giving a fish now and then is fine. Sometimes people are hungry. But remember that if the client can catch a few fish, they will be able to feed themselves long after your work with them is done. Finally, remember how you react when someone offers you an obvious but generally unhelpful “coping” thought for a particular situation vexing you. If you are upset, even the kindliest offer of a coping statement like “It really won’t matter after today” or “She did not know how much you cared; she wouldn’t have done that otherwise” can push us into a strongly oppositional mood. I like to remember that if it were as simple as someone pointing out the “errors” in our thinking, then there would not be any need for cognitive therapy. Our caregivers and friends have been telling us to think more positively for years. With that prelude out of the way, let’s spend a little time getting to know what cognitive can look like in exposure therapy. First, it is critical to establish with the client the two important foundational ideas we discussed in Chapter 2: (1) thoughts, behaviors, and emotions comprise a mutual influence cycle and (2) efforts to change any one of the three may therefore lead to changes in the other two. Cognitive interventions are thus based on these two notions and their aim is to help clients learn ways to influence their thoughts, thereby influencing their behaviors and emotions. A variety of ways to influence thoughts have been developed. In this section, I walk you through a few of these interventions and provide a few case examples to bring them to life. I conclude the section with some



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considerations about how one integrates these approaches into exposure therapy.

Thought Identification With what I call thought identification, you seek to help clients achieve two goals: (1) identify their thoughts and (2) note common thinking patterns. The first goal means helping clients observe and articulate their thoughts. That step sounds easy, right? For many child (and adult) clients, it takes some practice. Imagine your thoughts as water in a river. Most of us have a wide and deep river’s worth of thoughts. However, often, much of the river is unseen; we see what is on the surface when there is considerable volume just underneath. Bringing thoughts to conscious awareness requires practice and that practice represents the intervention. The good news is that observation of thoughts can occur anywhere because thoughts are omnipresent. A quick example may help illustrate this goal. Here, the client is Hope, a 14-year-old girl who is a chronic worrier, especially about her health, though also about her performance across many contexts, including school and her instrument, the viola. Therapist: I want to try this idea about thoughts out a little. I have an exercise I do with teens sometimes. Let’s give it a try. Let’s pretend that we have a camera that can take pictures of your thoughts. The idea of a camera is important, so let me explain. What does a camera do? Hope: Um, well, it takes a picture. Therapist: That’s right. Like let’s say you are taking a picture of your dog, Echo, when he is looking up at you. Can you imagine that? Hope: Yes. Sometimes when he looks up at you, it looks like he winks. It is really cute. Therapist: Perfect. So imagine he is looking at you and winking. And you take out your phone and take a picture. Snap. So now look at the picture on your phone. What do you see? Hope: Um, well, I see Echo looking at me. Winking, I guess? Therapist: Yep. Except, is there anything in the picture that tells you it’s Echo? Hope: What? Um. I know it is Echo. Therapist: Right. But if someone who did not know Echo saw the

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picture, would the picture be enough for them to know it was Echo? Hope: No. I guess not. Therapist: Right. You know his name. But his name is not part of the picture. Neither is the fact that he is the cutest dog in the world or that you have known him since he was a puppy or that sometimes he makes you laugh like crazy. None of that stuff is in the picture. What does the picture have? Hope: Well, I guess just a dog winking? Therapist: Yep. All of that other stuff is stuff you know but it is not in the picture. You are probably confused right now. I know I would be. That’s OK. We can start the exercise a little confused. Here is what we are going to do. We are going to make a camera for your thoughts. It will take pictures of your thoughts. One at a time. Let me show you first. Right now I am thinking, “I hope I can show Hope how to do this.” (Writes on pad.) and now I am thinking, “I wonder what Hope thinks.” (Writes on pad.) Let’s try with you. What is your thought right now? Take a picture. Hope: (Looks puzzled.) Um, I am confused. Therapist: That is your thought, then (writing), “I am confused.” What else? Hope: Oh, I get it now. Therapist: (Writes.) “Oh, I get it now.” Hope: Took me long enough. Therapist: (Writes.) “Took me long enough.” Hey, I think you are getting the hang of this. Let’s shift to something a bit more challenging. How about you imagine you notice your mom sneeze? What thoughts come to mind? You just say them and I will write them down. Mom sneezes and . . . go. Hope: Um, she might be sick? Therapist: (Writing) Got it. What else? Hope: Maybe she has pneumonia? Therapist: OK. Got it. What next? Hope: Well, if she has pneumonia, she might go to the hospital. Therapist: OK. (Waits.) Hope: What if she dies? Therapist: (writing) That is a big one. Let’s pause here for a minute.



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In this part of the session with Hope, the therapist focuses on thought identification. A common next step is to note thinking patterns. Before I say much more about these patterns, let’s continue with the example of Hope to show how her therapist handled that step. Therapist: I wrote down your thoughts that happened when you imagined your mom sneezed. Let’s take a look—and let’s look like those folks on CSI would look, all sciencey. We will look at each thought and classify it into a few different categories. Let’s call category #1 thoughts that made you feel more anxious or worried and category #2 ones that made you feel less anxious or worried. What other categories should we consider? Hope: Um, how about if it does not change my anxiety? Therapist: Great! Let’s call that #3. Another? Hope: Um, maybe it could make me feel a different feeling? Therapist: You are great at this! Yes—let’s say #4 is that it makes another feeling happen or change. How does that sound? Hope: OK. Therapist: All right. (Checks notepad.) First thought was “She might be sick.” What category does that one go into? Hope: More anxious. Therapist: Sounds right—that was #1. Next one was “Maybe she has pneumonia.” Hope: More anxious. Therapist: “If she has pneumonia, she might go to the hospital.” Hope: More anxious. And the next one was that too. Therapist: OK—right. “What if she dies?” That would definitely make me a lot more anxious. There was a pattern there for sure. Lots of category #1. When we feel anxious, it can be easy to think of thoughts that make us even more anxious. And it can be tough to come up with ones that make us feel less anxious. Or that even don’t change our anxiety. Working on this stuff is like working on any skill. We have to practice. A lot. How about we work on coming up with some thoughts that might not fall into that first anxiety-making category. When helping clients understand thinking patterns, using a threeor four-tier system like Hope and her therapist did is often adequate. You

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can also consider identifying the common thinking traps that cognitive therapists have enumerated over the years. A few of these are listed here. • All-or-nothing thinking: thinking of outcomes or situations in absolute versus relative terms. Examples: “I will never do well at math”; “I always mess up in soccer.” • Arbitrary inference: AKA, jumping the gun. When someone draws a conclusion quickly and on the basis of limited evidence. Examples: “That person did not smile at me. He hates me”; “I got the first answer wrong on the test. I will fail.” • Catastrophization: AKA, mountain out of a molehill. When someone assumes that an outcome will be magnificently bad, often out of all proportion to the situation. Example: “My friend is mad at me. I will never have another friend again”; “I think I did badly on the history final. I will fail and my parents will ground me for life.” • Mind reading: When someone assumes that they can read others’ minds and/or intentions. Examples: “My boyfriend hasn’t called me today. He is angry with me for some reason”; “My teacher is looking at me funny. She is thinking I am an idiot.” • Overgeneralization: When someone takes one negative event and assumes that it has meaning that pervades their whole life. Example: “I missed that shot. I am never going to make another shot.” • Selective abstraction: AKA, looking for the bad news. When someone focuses only on some of the available evidence in order to draw a conclusion. Example: “My teacher mentioned that my report needed some edits. He hated it.” With thought identification, including thinking patterns, under our belt, it is time to transition to the cognitive intervention that, in my view, is the stereotypical way to do cognitive work: cognitive restructuring.

Thought Investigation I personally find the commonly used name of this strategy, “cognitive restructuring,” misleading. Rather than restructuring thoughts, the goal is to encourage the client to alter their relationships with their own thoughts, to view themselves as an observer and consumer of those thoughts—hence, the title of this section, “Thought Investigation.” Whereas clients may not be able to remove fully some thoughts that lead



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to higher levels of anxiety, they can push back on those thoughts with evidence, and add new and less anxiety-provoking thoughts into the mix. Remembering their impartiality squad badge, the therapist works like Socrates with the client to explore and gently interrogate thoughts. Good questions to have ready include the following: • “What is the evidence for (and against) the thought?” • “What would the consequences be of believing and/or acting on the thought?” • “What other thoughts are there?” • “What thoughts will help you act or feel in the way you want?” The end goal is not to remove anxious thoughts and add coping ones. Instead, the goal is to help the client notice when they have anxious thoughts, to be able to talk back to these thoughts by requiring evidence before they accept them as true, and to have a few coping thoughts at the ready to balance out the anxious ones. A soup metaphor may help. Once you have the soup cooking, you cannot remove some of the ingredients, even if you have too many or too much of them. Instead, you can add new ingredients that either balance out the problematic ingredient or add ingredients that provide a different experience altogether. For example, if the soup is too salty, you can add more water to dilute the salt or drop in a potato to absorb some of the salt. Alternatively, with soup, you can amplify other flavors so that they rise to the level of saltiness you have. Let’s return to Hope and her therapist to see how to work on this final step in “cognitive cooking.” Therapist: Let’s stay with this situation where you mom sneezes and you are able to come up with a lot of thoughts that make you feel more anxious. There are lots of different ways to come up with other thoughts. Let’s try a few and see how they work? Hope: OK. Therapist: One way is to keep our scientist lab coats on and to head to the laboratory to look for evidence. What is evidence? Hope: Like proof of something? Therapist: Right. Evidence is something that we can use to prove that our idea or hypothesis is on the right track. Remember we said our thoughts are like guesses, which are like little theories. So, when we have a thought, it is like a theory. We can

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ask ourselves, “What is the evidence for that thought? What proves that it is true?” Let’s try that. We can start with the first thought: “She might be sick.” What is the evidence for that idea? Hope: Well, sneezing could mean someone is sick. Therapist: True. Good. That goes on the for side of evidence. What else might sneezing mean? Hope: Could be allergies, I guess. Therapist: OK. Right. So that goes in the against side. Other reasons someone sneezes? Hope: Some people sneeze when they get something in their nose, like dust or something? Therapist: That happens to me. Like when I go into a dusty room. Does that mean someone is sick? Hope: Um, no. Probably not. Therapist: OK. (writing) Putting that one in against. Any others? Hope: I can’t think of any. Therapist: I have a nerdy one. It is called the “photic sneeze reflex.” I only know about it because I have it. Like 20% of people have a sneeze reflex when they see a bright light, especially the sun. It is kinda wild when it happens to me. Hope: Weird. As you can see, cognitive work can be painstaking. I like to think of it as a slow jam. It is best to take your time with cognitive skills because there are no shortcuts. You may think you can make it go faster by doing a lot of fishing for the client. But because you are aiming to teach an approach like seeing the whole court rather than a concrete skill like dribbling, you need to take your time and go through a lot of examples. As I noted at the outset, this was a quick run-through of cognitive work. The references listed at the start of the section are a good place to start if you want to read more about this kind of therapy. I will switch gears now to one last skill that is common in many CBT programs for anxiety: problem-solving skills.

Problem-Solving Skills Problem solving has usefulness across many clients. It is found in 33% of all programs that work for any problem areas (www.practicewise.com).



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For most therapists reading this book, problem-solving skills will be a familiar technique. There are entire books dedicated to problem solving and so this will not be an exhaustive review. It will, however, help you see how problem solving may be useful with anxious youth as part of exposure treatment. Most problem-solving approaches involve teaching the client a systematic approach to solving problems. The approach is designed to be generic, so as to fit most problems a person will encounter. As described here, problem solving is not ideal for emergent problems or imminent crises. Instead, problem solving is best used for problems that are in progress, developing, or unfolding, but that are not creating an emergency in the present moment. Although there are many different ways that problem solving is presented to youth, it most commonly involves four steps.

Problem Definition Step 1 is problem definition. In my opinion, this step is the most important one and yet it is the one often taken for granted. In step 1, you are identifying the problem that needs some management. There must be a collaboration between client and therapist here. The therapist ought not take the first idea the client offers. Still, they need to listen to, acknowledge, and empathize with the client. Too often, therapists attend to major, broadly defined, and usually insoluble problems. Examples may include “School is too stressful”; “I cannot live without my parents”; “I am not cool enough.” Defining the problem like one of these leaves us with an overly broad challenge to tackle. The goal in problem definition is to identify a concrete problem that has some potential solutions that can be attempted in the short term. Once managed, that sort of problem can be a step in addressing the big, broad problems. You know what they say about having one success? Let the snowball start rolling down the hill. Let’s reconsider a few big problems in light of the goal to select a more manageable problem that is related to the theme identified (see Table 5.1).

Brainstorming Solutions Step 2 involves brainstorming ideas to try to solve the problem. As most folks know, the key to brainstorming is that all ideas are welcome. It is particularly important that any currently used strategies are included in the list, even if they create problems for the client. That means that if the

94  EXPOSURE THERAPY WITH CHILDREN AND ADOLESCENTS TABLE 5.1.  Problem Definition Example Large, hard-to-manage problem

Related bite-sized problem

“School is too stressful.”

“I am having trouble in math class.” “I have trouble talking in class when called on.”

“I cannot live without my parents.” “I am afraid when my mom is late coming home from work.” “I get afraid when my dad or mom get sick.” “I am not cool enough.”

“I have only two friends.” “I don’t know what to say when someone talks to me in class.”

client does not generate the idea, you will need to do so. When generating ideas, it is also important to forestall judgment of any of the ideas. Just let the ideas flow—“anything goes” in this step. Your job as therapist is to ensure that the list is balanced with reasonable and adaptive ideas and ideas that are less ideal or even problematic. Table 5.2 provides some examples from our earlier set of problems.

TABLE 5.2.  Brainstorming Example Problem

Ideas to help

“I am having trouble in math class.”

•• Get extra help from the teacher. •• Get tutoring. •• Get help from a classmate. •• Drop out of the class. •• Fail the class.

“I am afraid when my mom is late coming home from work.”

•• Call my mom. •• Ask her to call before she leaves. •• Remember the times she has come home late and been safe. •• Imagine her being hurt. •• Cry.

“I have only two friends.”

•• Be satisfied with two friends. •• Meet new people by joining a club or team. •• Talk to any friends of your two friends. •• Spend time online looking at other people’s social media accounts. •• Sit with new people at lunch or on the bus.



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Evaluating Ideas With a set of ideas in hand, you move on to step 3: idea evaluation. Here, you walk through the pros and cons of each idea. It is important to keep your impartiality squad badge on here. The recommended stance is a humble one: you do not know what strategies are going to work for any given client. Their situation is different enough from any other one to warrant modesty on your part. You may feel like you know the exact right thing to do, but it may not work for any number of reasons when tried by the client. Instead, you engage in an impartial but thorough vetting of each idea. Table 5.3 walks through the pros and cons of one of the possible solutions to the problem “I only have two friends.”

TABLE 5.3.  Problem Definition Example Ideas to help

Pros

Cons

Be satisfied with two friends.

•• I already have two friends. •• My two friends are awesome.

•• Having only two friends means I will be lonely sometimes. •• What if one or both of them move away? •• What if I get sick of one or both of them (or they get sick of me)?

Meet new people by joining a club or team.

•• They would like the same stuff I do. •• I would see them at the club or team meeting. •• I might have fun.

•• Joining a new thing is hard for me. •• What if I am not good at the sport or club activity? •• What if no one likes me?

Talk to any friends of your two friends.

•• They might like me since they like my friends. •• It would be easier to meet them than someone new.

•• I am not sure how to meet them. •• What if they don’t like me?

Spend time online •• Being online is easy. looking at other people’s •• I like looking at social social media accounts. media sometimes.

Sit with new people at lunch or on the bus.

•• I might meet someone new that I like. •• If I did make a friend, I would see them a lot.

•• Sometimes social media makes me feel bad and lonely. •• I might see my friends doing things without me. •• Super scary for me to do. •• The people might not like me.

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Choosing an Idea and Trying It After a thorough and balanced review of each idea, step 4 involves choosing one, giving it a try, and seeing how it worked. If progress in the right direction is present, shout “Hurrah” and keep at it. If things went awry, troubleshoot and either try the same idea again (perhaps it was not implemented correctly) or start the problem-solving loop over again. Step 4 always has a persistence aspect to it, as in the old adage, If at first you don’t succeed, try and try again. Problem solving is a simple enough process to teach and practice in sessions. That may be why it is such a ubiquitous strategy across child and adolescent treatments. Let’s close out this section with an example of how you might process step 4 after a client has tried an idea and it did not go splendidly. In this instance, the client is Liam, an 11-year-old boy whose problem was that he only had two friends. The therapist, Liam, and his mom had settled on him joining a new club. Aikido was selected as there was a class nearby and the price was reasonable. Therapist: How did class numero uno go? Liam: Not good. Therapist: Bummer. What happened? Tell me about it. Liam: Well, it was really hard. Therapist: The moves were hard? Liam: Yeah. Therapist: What else was hard or not good? Liam: Well, the other kids kinda already knew each other and they were good at the moves, so not good. Therapist: Gotcha—so this was your first class but not the first class for the other kids? Liam: Yeah. Therapist: Were you the only new kid? Liam: Um, no. There was another new kid. Therapist: OK. You and the other person were new? Liam: Yeah. I felt awkward. Therapist: When we planned things out last time, we came up with some predictions for how it would go. Let’s see if any of them came true. (reading) It will be hard. True? Liam: Yeah.



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Therapist: The other kids will hate me. True? Liam: I don’t know. Therapist: OK. Let’s put on our judge’s robes and look at the evidence. (Pretends to put on a robe and offers one to Liam.) Liam: (Smirking, takes the fake robe.) Therapist: So, what is the evidence for the kids hating you? Liam: They didn’t talk to me? Therapist: OK. What else? Liam: Um. Nothing else I guess. Therapist: OK, what is the evidence against the kids hating you? Liam: I don’t know. Therapist: Well, let’s ask some specific questions. How many kids said they hated you? Liam: (Smiles.) Zero. Therapist: How many wrote you a note that said they hated you? Liam: None. Therapist: OK. Time to look for contrary evidence. Can you remember anything they did that was friendly or the opposite of hating you? Liam: Um. Not really. Therapist: Let me get more specific. Did any of them offer to help you? Liam: Um, yeah, one kid I paired with, he showed me how to tie my belt and he also showed me the right way to grab him. Therapist: OK. Good evidence there. How about did any of the kids talk to you? Liam: No. Well, wait, yeah. The other new kid waved good-bye to me. Does that count? Therapist: What do you think, judge? Liam: I guess it sorta counts.

Using Problem Solving in Exposure That pattern of problem-solving steps is likely familiar. The approach is commonly used in anxiety treatments and can be quite helpful in doing exposure specifically. A therapist may use problem solving to generate

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ways to approach or expose the client to feared stimuli. This is particularly common with social exposure, when selecting peers to include in exposure tasks. Thinking through pros and cons of specific peers can be helpful in heading off potential problems. Problem solving can also be used when a client is experiencing anxiety during an exposure. Many programs emphasize use of problem solving like this. The problem becomes the heightened anxiety and the various solutions are often coping skills to consider using and/or approach strategies to adopt. Finally, I always emphasize to clients that exposure is an important tool to add to their problem-solving toolbox. When anxiety rears its head, the client can grab that exposure tool and use it with skill. Thus ends a brief overview of three common coping-skills interventions found in exposure treatment. Next, I turn to how exposure is varied across several different problem areas.

CHAPTER 6

Exposure for Specific Phobia

Chapter 4 provided a foundation for delivering exposure in a generic

way. Each of the next five chapters will add individualized procedures on that foundation. I begin with specific phobias and then work my way through each of the following problem areas: social anxiety, separation anxiety, panic, and generalized anxiety/worry. Each of the chapters that follow will share a common structure. I begin with a brief description of the problem and common presentations. Then, I describe how the exposure procedures are varied for the problem. Clinical examples are used throughout.

Description The procedure of exposure is particularly well suited for phobia in part because many of the earliest iterations of the approach were designed and tested for these problems. A phobia is an out-of-proportion fear of a specific stimulus. The stimulus is feared to such an extent that it is either avoided entirely or, if impossible to avoid, is endured with extreme distress almost every single time. Phobias are common in children and adolescents, with prevalence rates as high as 19% reported in the literature. Long-term impairment from phobias tends to be less severe than with other anxiety disorders; however, there is tremendous comorbidity of phobias with other anxiety disorders. Exposure treatment with phobias involves providing a client with practice approaching and engaging with the feared stimulus. As a result, exposure for specific phobia involves the least amount of adjustment 99

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from the generic description in Chapter 4. The complexity of treating specific phobia lies in the fact that the types of stimuli people can fear are so diverse. Certain phobias are more common in treatment settings (e.g., specific animals, needles, medical procedures, the dark, heights), but one can have a phobia for almost any stimulus imaginable. For the purposes of this chapter, I will focus on a few of the more common phobias that are seen in clinical settings. The basic principles presented in Chapter 4 apply to most if not all stimuli. Although phobias are quite common, children with phobias do not commonly present for treatment at community agencies, possibly due to the relatively lower impact that phobias can have on the functioning of youth compared to other problems (e.g., depression, social anxiety, disruptive behavior). As noted, phobias were the initial proving ground for exposure therapy; the procedures described in Chapter 4 are tailor-made for most situations. The procedural variations discussed for specific phobias include (1) the pattern of the phobia fear ladder, (2) planning a graduation exposure, (3) the trials of phobia exposure, and (4) the role of cognitive skills with phobia. In this chapter, I walk through each of these in turn, using two clinical examples, the cases of Jessica, a teen with a fear of needles, and Marcus, a young boy who fears dogs.

The Pattern of the Phobia Fear L adder I’ve said to focus on one stimulus; that sounds easy, you say. Then perhaps you remember that the first step is to build the fear ladder. How many ladders do you know with one rung? Obviously, you will need to identify ways to take the one stimulus and create variants of it that are arrayed along a continuum of anxiety creation. How? A solid rule of thumb is to start with words, move to representations of the stimulus, and build to the stimulus itself, in vivo. Let’s walk through two examples. Jessica was a 15-year-old living with her mother and younger brother who was brought to the clinic for worries as well as a specific fear of needles. The latter received most immediate treatment focus because Jessica had been diagnosed recently with diabetes and was going to need to be around needles often to manage her illness. Early rungs on the fear ladder included talk about different kinds of needles, their functions, and their appearance. For Jessica at the start of treatment, even discussing needles was anxiety-provoking. The therapist developed



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an expertise with the names and types of needles and used that knowledge to teach Jessica about the different gauges of needles as well as the difference between the lancet used to test blood glucose levels and the injection needle used for insulin. Once the talk about needles because less anxiety-provoking, the next rungs of the ladder involved pictures of the different needles, initially alone, and later in use. Next, the exercises progressed to videos of different needles in use. The final rungs of the ladder involved the use of different needles, first on oranges and other foods, concluding with actually conducting blood tests in session. In preparation for the final rungs of the ladder, the therapist assisted Jessica in developing competence in holding and using the different needles, including their safe disposal. Another example is that of Marcus, a 7-year-old boy who lived with his parents and two older siblings. Marcus had developed an intense fear of dogs after having heard of a boy in his neighborhood who was attacked and injured by a dog. The family did not have a dog but had long wanted one, having waited until Marcus was older. Marcus’s new fear was standing in the way of the family’s desire for a pet. Similar to Jessica, the fear ladder for Marcus initially involved talking about dogs. In fact, the intake session and the sessions hashing out the fear ladder were themselves exposure sessions, as dogs were a central topic of conversation. The early rungs of Marcus’s ladder focused on reading and learning about dogs, including the names of different breeds and their purposes as well as how dogs came to be domesticated. The middle rungs for Marcus focused on different images of dogs, starting with cartoon stills and moving to photos of actual dogs, and then to videos of actual dogs interacting with people. The final rungs of the ladder involved witnessing and then participating in interactions with dogs. These final rungs warrant some discussion, as exposure to animals is a bit more complicated than exposure to needles. With needles, you can predict the behavior of the stimulus consistently. A needle won’t make any unexpected moves by itself. An animal (including other humans, as I will discuss in later chapters), on the other hand, can be unpredictable. In my experience, it is easier to find dogs who are good helpers in exposure tasks than it is to find cats who are. There are always those cats who love human contact and whose owners claim they “think they are a dog.” But cats in general are harder to predict and they are often more ambivalent of human interaction. With cat fears, I cannot emphasize how important it is to identify a cat whose behavior is highly predictable. With the heightened fear of the client in exposure situations, there is risk for a fearful or erratic animal to exacerbate a client’s fear. As

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most readers are painfully aware, some cats can contentedly receive your petting one moment and lash out at you the next without any warning. So, know the cat you are using well. The same advice applies to dogs, though dogs are generally much easier to use in exposure situations. There is a reason that dog obedience schools are common and cat obedience schools are not. Also, it is good to remember that dogs have co-evolved with humans over many centuries; dogs are keen perceivers of human body language and are predisposed to collaborating with us. Still, you should be highly familiar with the dog or dogs you plan to involve in exposures. It can be quite useful to use different dogs, especially if those dogs are different across multiple dimensions: size, energy, friendliness. However, you want to select dogs who will make for good initial or re-introductory experiences. For this purpose, well-trained dogs who respond quickly to commands and are familiar with interactions with children are best. With most clients who fear dogs, the last set of rungs involving interactions with dogs make for a dramatic and enjoyable finish. The stimulus in question, a dog, has so many ways to be naturally reinforcing that once a client can engage with low levels of fear, those reinforcers become potent. However, there are some clients who will struggle most at the end point due to previous traumatic experiences with a dog or, as in Marcus’s case, knowledge of a traumatic experience. In such cases, the fear ladder must be built with this knowledge in mind and there is often some extra work needed to address the complexity. Related to the ladder, the therapist will need to consider the details of the dog(s) involved in the traumatic event. In Marcus’s case, it turned out to be a German shepherd who was kept chained in front of a house when the owner was not home. Accordingly, the fear ladder across easy, medium, and hard levels included German shepherds at the top. Thus, the final exposure for Marcus involved interacting with a German shepherd.

The Graduation Exposure Marcus’s final item brings us to another important point that is common to phobia exposure, but often less applicable with other problem areas: the graduation exposure. Because of the discrete nature of the feared stimulus, the fear ladder sometimes leads to a logical final rung that can be conceptualized as the graduation step. Good graduation items are based on the client’s input, rooted in the goals of treatment, and represent clear evidence that the fear the client had at the start is truly conquered. For



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example, in Marcus’s case, recall that his family was motivated to adopt a dog. Thus, the graduation item needed to involve active and ongoing interaction with a dog, since Marcus would soon have a dog living in his house. Marcus, his family, and the therapist landed on a graduation item that involved taking an adoption-candidate dog, Emmy, for a walk that included opportunities to give the dog commands and offer rewards. As it turned out, Emmy shortly thereafter joined Marcus’s family. In other cases, the graduation item may not require such an intense level of involvement with the stimulus. Consider fear of spiders. It is the rare individual who needs to spend time interacting with spiders. We rarely need to build strong relationships with spiders. Still, we do need to encounter them in our daily lives without screaming and panicking. Accordingly, a graduation exposure may involve completing a variety of normal daily tasks for the individual in a room that has multiple spiders planted around it. For example, one might assign a client to prepare, consume, and then clean up after a meal in a room that has had spiders placed around it.

Making the Trials of Phobia Exposure Consistent You will recall that multiple trials are a key in exposure. One cannot extinguish a fear by facing it a single time. Instead, one must face the fear over and over (and over) again, so that one can learn that the stimulus is not as harmful as expected, that the situation is, in fact, a false alarm. As noted in Chapter 4, this is accomplished through conducting multiple trials of the same item from the fear ladder to ensure that the client learns that fear reduces when faced with a stimulus and that over time, initial fear reduces with each exposure. An important technical component for constructing trials is maintaining consistency of the stimulus within trials. Remember, the idea here is to identify a discrete stimulus or situation and then present it in an unvarying way across multiple trials. It is the unvarying aspect of the activity that can be a challenge for some stimuli (especially as we will see in later chapters). Fortunately, with phobia, maintaining stimulus consistency is often easy to do, especially with early items. Pictures and videos can be presented consistently over and over again. But there are some common challenges that arise even with phobias. Let’s consider each in light of an example. Recall Marcus who had a fear of dogs. For later trials, one item on the fear ladder was for Marcus to remain in a room with a leashed dog. Keeping the same dog is somewhat easy to do with preparation.

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However, even a leashed dog moves around some. As a result, the stimulus in this case varies some from trial to trial. You can troubleshoot this by taking ratings when the dog behaves in different ways, helping the client and the therapist to understand what influences the client’s fear. Fortunately, with a well-trained dog, the variations can be minimized. There are other stimuli, however, that are not as easily managed. With those, you do your best to keep the stimulus as consistent as possible, gather ratings, and celebrate the client’s success at handling the chaos. Another challenge in maintaining a consistent stimulus is a more covert one: the (usually) inadvertent stimulus variation caused by the therapist and the client. To explain this one, I have to go back to your research class in college or graduate school, when you learned about internal and external validity. Internal validity is concerned with ensuring that you can feel confident that your independent variable and not some other confounding variable has led to any changes in or relationships with the dependent variable(s). Remember—the independent variable is the one that you control as the researcher—like an intervention you are trying. Confounding variables are the ones that make it tougher for you to know if it was your intervention and not the confounding variable that led to a change. The dependent variable, finally, is the outcome we want to see. For example, trying to help Marcus become less afraid of dogs would be our dependent variable, and using exposure to dog-related stimuli would be our independent variable. In this example, confounding variables would be Marcus on his own learning about friendly dogs, a new movie he sees about dogs that shows dogs as amazing friends to kids, or the neighbors adopting a super-friendly dog who takes a liking to Marcus. Internal validity is a reason why a lot of research occurs in controlled laboratories and the reason that almost any and all conversation with the participants is controlled by the scientist with a script. You never know what differences might make a difference. When I talk about keeping the stimulus consistent, I am in some sense talking about internal validity. You want to help the client understand that fear will decrease if they confront the same stimulus over and over, with the emphasis on same. The world, though, is a complex place and exposure trials do not occur in a vacuum. For one thing, you, as the therapist, are present and interacting with the client before, during, and after trials. To the extent that you vary your own actions and words before, during, or after each trial works against the keep-it-the-same goal. Of course, it is nearly impossible to remain exactly the same—and may even be robotic and thus potentially distracting for the client. However, to the



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extent possible, I encourage you to remain as consistent as possible in your words and actions. A good rule of thumb is to (1) have a “schtick” for the before (e.g., identify the item on fear ladder; establish a prerating; determine any predictions for how it will go) and after (e.g., praise; establish a postrating; check in on outcome of predictions) huddles and (2) keep it minimal (e.g., request ratings if needed, say little else) for the during. Thus, having a structure and a script is a good start. More challenging, though, are all the subtler ways that you as therapist can change the situation. Much of these changes come about because of reflexive social actions we take as therapists because we have welldeveloped social and emotional skills. For example, some clients will ask questions or talk during exposures. It can be natural for the therapist to reply: this is natural but contraindicated except in emergency situations. Talking during exposure is often a distraction and can serve as a safety signal for a client. Yet it can be a challenge to ignore a client’s question without feeling like a bad person and a terrible therapist. You can mitigate this challenge by making the ground rules during exposures clear: before and after, you can talk, but during the exposure itself, you will take ratings and have almost no other talking. An obvious and yet sneaky way that therapists can change the stimulus has to do with the temptation to let the stimulus change a bit each time because the client is doing well. Take Jessica’s case as an example. Early in treatment, one set of trials concerned photos of needles. On one particular photo, Jessica’s first rating was low and she exhibited almost no fear. The therapist was tempted to move to the next rung on the ladder rather than repeat what was apparently an easy task. Sometimes, clients will ask to move to the next level. “This is too easy. I am ready for something harder.” In these situations, one must remember that the goal of the exposures is not only to see the client’s anxiety decrease when confronting the stimulus. The larger goal is to help the client learn that if they put themselves in situations that are safe but that frighten them multiple times, it gets easier each time and it becomes less frightening each time. The importance of multiple trials is to help the client understand the trick to overcoming fears: exposing yourself over and over to the feared stimulus. The danger in changing the stimulus too often or too quickly is that a client may instead learn that just as they begin to feel a little more comfortable with a frightening stimulus, it changes to become more frightening. Allowing the client to master each rung of the ladder builds confidence for the next rung, whereas hustling them up the ladder teaches them that they can get to the top but it may not produce the same level of certainty and confidence that they can do it again.

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Cognitive Skills and Phobia I close the chapter with a brief discussion of whether and how one might integrate cognitive skills into exposure for youth with phobias. Although CBT is now a ubiquitous treatment approach, the marriage of “C” and “B” was (and for some still is) a point of contention. Some behaviorists eschew the black box of cognition altogether and still others take a dim view of the use of cognitive approaches. Also, as noted earlier, evidence suggests that one need not teach and practice cognitive skills explicitly for exposure therapy to be effective in reducing anxiety. Yet, cognitive strategies may sometimes prove helpful for some cases. Although Chapter 5 covers cognitive skills in a bit more detail, a brief discussion of how one might apply cognitive skills specifically for phobias is worth a few paragraphs. For phobia cases, the cognitive strategies used are often limited in scope and time. One can often forgo the direct teaching of cognitive skills, instead using the planning and debriefing huddles as time for some on-the-spot cognitive training. The training takes the form of identifying predicted outcomes for a particular trial in the planning huddle, reflecting on how that prediction influences anxiety level, and then reassessing the prediction in the debriefing huddle. Repeating this basic process across multiple trials may facilitate cognitive changes without much need for explicit cognitive training. Another way to introduce cognitive strategies into exposure for phobia is through education about the stimulus. I already discussed the importance of psychoeducation about anxiety, the distinction between false and true alarms, and the rationale for exposure for successful exposure therapy. For phobia, it can be quite helpful to educate clients about the stimulus itself. Because of the fear, clients often lack basic knowledge about the feared stimulus and sometimes have misperceptions. For Marcus, the therapist spent a few early sessions engaging in exposure trials that amounted to education about dogs: their different breeds, how breed determines behaviors, how to pet dogs, and so on. Through education like this, a client is not only completing an exposure to talking about a stimulus: they are creating and/or challenging beliefs about the stimulus based on evidence provided by the therapist. In Marcus’s case, the therapist did not strive to convince him that all dogs were safe and loving. Instead, the therapist helped him understand how dogs evolved to be with humans and how their different breeds behaved in different ways around humans. The information replaced his limited and fear-generated ideas about dogs. And the new information can then



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be applied in future exposure situations. In Marcus’s case, the therapist referred back during exposure trials to the educational information, asking Marcus what breed this might be or whether the dog appeared to be receptive for petting. The recollection of the educational material promotes changes in beliefs about the stimulus toward more benign, less threatening ones, thereby increasing chances of successful exposure in the future. Of course, you will have some clients with phobias for whom a more formal training in cognitive skills seems warranted. These are often cases with multiple anxiety diagnoses, such as social anxiety or generalized anxiety/worry. For such cases, the chapter on coping skills will be helpful. Exposure with phobia often looks most like the generic version described in Chapter 4. Although I discussed a few variations for phobias, as you will see, other anxiety disorders typically require a lot more adjustment.

CHAPTER 7

Exposure for Social Anxiety

W

e turn next to a problem area that was once classified as a phobia: social anxiety. I begin with a brief description of the problem, as well as common presentations. Then I will describe variants of the basic exposure procedures outlined in Chapter 4 relevant for social anxiety.

Description The nomenclature for social anxiety problems has evolved in the DSM. Up through the third revised edition (DSM-III-R), the constellation of problems was called social phobia. In DSM-IV, social anxiety disorder was offered as an alternative label, and that name became the preferred term in DSM-5. Despite the name change, social anxiety disorder does have a lot in common with specific phobia in terms of the intense fear of a specific situation and a tendency to avoid the situation strongly. Social anxiety is common and is also a common reason for treatment referral in children and adolescents. A primary reason for its commonness as a reason for referral is that, if unchecked, social anxiety can cause notable impairments across several domains of functioning. Children with severe social anxiety often have poor social functioning; they experience academic struggles, especially as they get older and class presentations and interaction are used as part of the grading process; they experience challenges in family relationships, as their desired avoidance of social situations can create notable family strain; and, finally, they can experience notably high levels of internal distress. Social anxiety disorder is quite heterogeneous in presentation, with some children 108



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having circumscribed social fears such as fear of giving a speech in class, whereas others can have highly generalized social fears that can include class presentations and other performance situations as well as more mundane social interactions, such as initiating, maintaining, and terminating social contact with others. Social anxiety disorder and specific phobia do share in common the fact that both involve a relatively concrete set of stimuli to which exposure can be put to good use. Exposure with social anxiety disorder can have a number of unique and complex variations. Because social interaction is easy to practice, identifying practicable exposure tasks is easy. However, because of the complexity of social interaction and because social skills are developmental achievements and always evolving, there are several points to consider as you begin this work. These points include (1) identifying appropriate social exposure targets, (2) clarity about the drivers of social anxiety, (3) assessing a client’s social skills, and (4) troubleshooting when social situations go awry.

Identifying Appropriate Social Exposure Targets for In-Session Exposure The great news about social anxiety exposure is that you, the therapist, are a prime stimulus for exposures. For most clients with social anxiety, the therapist is an anxiety-producing stimulus and a good exposure therapist takes full advantage of that by taking ratings early in treatment and helping the client see if and when those ratings come down as the therapist and client become better acquainted. Practices with the therapist are often the first social anxiety exposures that a client will do—and they do them from the jump! However, in many cases (hopefully!), the therapist’s value as an exposure target quickly diminishes. That is, the client becomes more comfortable talking with the therapist. This is an important achievement and quite obviously a requirement for moving forward in therapy for most clients. The need to move beyond the therapist for social exposures raises some challenges. Let’s begin with a description of two case examples that I will use throughout this section to demonstrate some principles to consider when conducting social exposures. Savannah is a 14-year-old high-schooler whose primary social concerns relate to school performance situations. An A and B student, she has struggled most in classes with high demands for participation. She fears raising her hand in class, is terrified of presentations, and has

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avoided the required public speaking class that is part of her high school curriculum. In social interactions with peers, she is soft-spoken and feels nervous. However, she has several good friends and her social functioning with peers is adequate. DeSean is a bright 11-year-old boy whose social anxiety disorder is focused primarily on peer interactions. He is afraid to make friends and start conversations; as a result, he also has concerns about how best to end conversations. He has more mild fears about presenting in class. As an exceptionally bright young man, he often knows answers to teacher questions and can raise his hand and respond. Though he feels some trepidation when he has to give a presentation in class, he rarely avoids such opportunities and his anxiety in these situations is relatively mild. Although he feels nervous in these structured social performance situations, he is able to perform well in them. However, DeSean struggles more with those unstructured social situations, such as on the playground, at lunch, or between classes in the hallway. Let’s start by presenting some items from these two young persons’ fear ladders. Savannah’s Fear Ladder Items • Giving a speech to a whole large class • Giving a speech to a small group from a class • Giving a speech as part of a group presentation in a large class • Giving a speech as part of a group presentation—practicing with the group • Raising her hand and answering a question in class (varies by teacher and subject) • Being called on in class to answer a question (varies by teacher and subject) • Talking with the teacher before or after class when peers are nearby • Talking with the teacher before or after class when peers are not nearby • Ordering in a restaurant • Asking a question in a store DeSean’s Fear Ladder Items • Introducing himself to a new peer who is with many other peers • Introducing himself to a new peer who is with a few other peers • Introducing himself to a new peer who is alone • Starting a conversation with a friend who is with other peers



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• Starting a conversation with a friend • Saying “Hi” to a peer he knows already who is with many other peers • Saying “Hi” to a peer he knows already who is with a few other peers • Saying “Hi” to a peer he knows already who is alone Let’s begin first with how to approach Savannah’s fear ladder. There is some good news there: a therapy room can often be structured as a quasi-classroom or quasi-retail setting. A table can easily double as a school desk, counter at a store, or restaurant; an easel can double as a whiteboard; and you as therapist can be a teacher, shopkeeper, or waitstaff. And the earliest items also only require you and Savannah. You can pretend to be the shopkeeper at the store whom she needs to question about the location of an item or about a store policy. You can pretend to take her order at a restaurant. You can pretend to be her teacher whom she approaches with a question. For these earliest items, the challenge is that you will likely produce less anxiety than the real thing. To move to the next level with these early items, we need to talk about logistics a bit.

Leaving the Office for Exposures There are a few key questions to ask yourself to get us started. First, can you leave your office during a session? There are at least two distinct domains to consider when an answering this question: (a) what is your own comfort in leaving your office and (b) what is your capacity to do so. Exposure therapy works best when the exposure targets are as close as possible to the actual feared stimuli, a fact that often requires that you leave the safety of a therapy room to go where the action is. This means you will need to be willing to leave your office and interact in public with a client. I will address the confidentiality issues shortly, as these are pertinent and important. The point here is that you may experience anxiety in venturing out of your office to conduct therapy. Being prepared for your own misgivings will be important. Therapists can harbor some unspoken, unacknowledged, and implicit biases or fears about how therapy should look. To conduct successful out-of-office exposure, those biases or fears often need to be overcome. Once your personal comfort is achieved, you still need to assess capacity. By this, I mean how accessible is your setting to good contexts for social exposures. Our training clinic is in an urban setting and is

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across the street from a grocery store, a coffee shop, a hardware store, several fast-food restaurants, and several retail stores. Thus, our capacity to find social stimuli for exposures within a short walk is quite high. If you are in a similar situation—in other words, close proximity to public businesses—then you have opened the door to a whole range of social exposures for Savannah and similar clients. She can order in the nearby coffee shop or ask questions in the store that sells hardware or video games. As one example, Savannah can find four different employees in a grocery store and ask each one a different question (e.g., Where is the cereal? What are the hours for the pharmacy? Where are the restrooms? Where is the customer service desk?). However, some of you may not be in such an advantageous location. When I encounter this challenge in our clinic, I hold our sessions off-site at an appropriate location. For example, one client was fearful about going to a mall related to social concerns. I met with the client for several sessions in the parking lot of an area mall, planned exposures in the car, and then headed into the mall for the work of the session. Alternatively, if the client’s home or school are near needed social anxiety exposure stimuli, the sessions could occur at or near those locations. If none of these options are feasible, a therapist is left with the option of structuring exposure tasks for the client to do themselves with a caregiver (or family member). This option involves considerable effort training the caregiver in the ways of exposure. Such work is critical for many cases anyway. As Wendy Silverman taught us in her excellent book (Silverman & Kurtines, 1996), a key goal is for the caregiver to learn how to be an exposure therapist. The transfer of control from therapist to client is a key goal in exposure therapy with children. So asking clients and caregivers to engage in exposures outside of session has to happen in most cases. However, that transfer typically requires copious modeling by the therapist about how to encourage clients to engage in exposures. Teaching the balance between pushing and supporting that makes exposure such a difficult approach is easier to do if the caregiver can observe the therapist do it and see it succeed.

Ground Rules for Leaving the Office I have covered the importance of your comfort with and capacity to leave your office for access to good exposure tasks. Before you head out, it is important to establish guidelines related to confidentiality and to set client expectations for the work that will occur in public. In a therapy office, it is quiet and private. You can talk as openly as you wish about



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your concerns. Once you leave the office, you introduce risks related to confidentiality. Others can overhear your conversation. Others will see you and the client together and may wonder about the nature of the relationship. Those with whom you intentionally interact may question what is happening. As a therapist in this situation, it is your job to walk through these considerations with the client and their caregiver in advance. Here are a few good tips we use in our clinic: 1. Establish with the client what you will say about the nature of the relationship if you meet anyone that one of you knows. Some clients may feel comfortable saying, “This is my therapist.” Others may prefer calling you a tutor or teacher. It will be important to have a conversation about this and help the client consider the pros and cons. Involving the caregiver(s) is almost always wise to do, as well. 2. Clarify with the client that all of the confidentiality requirements are still in place in public and inform them of the heightened risk of going out in public 3. Establish a basic ground rule that you will keep the conversation mostly focused on the task at hand and will reserve more personal topics for when you return to a private space. 4. Establish a method for collecting anxiety ratings in public. Some clients are OK responding to a simple request like, “Rating?” Others may prefer to point to a number on a card the therapist has handy. Still others may prefer recording their ratings on a card you provide. Note that all of these guidelines can and should be practiced in the office before heading out. As my advisor Phil Kendall used to say, “Practice in private, perform in public.” Reserve the therapy office for these private rehearsals and then head out for the live performance.

Practicing for Unexpected Scenarios In addition to ground rules, it is important to troubleshoot a few unexpected scenarios before heading out into public. In Savannah’s case, we practiced her ordering something at the coffee shop in the office before heading to the shop. In that practice, we focused first on basics (clear voice, body posture, eye contact, etc.). Then we rehearsed a few curveballs like unplanned responses from the shopkeeper (e.g., “What size?”; “What kind of milk?”; “Do you want whipped cream?”) as well

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as unexpected events related to (e.g., “We are out of that”; “We don’t carry that”; “Please repeat that—I did not hear you”) and unrelated to (e.g., “Is it still raining out there?”; “Cool shirt!”) the ordering process. Troubleshooting in advance can help the client be ready for these challenges. Of course, it is impossible to predict what these challenges will be and thus not possible to practice all of them in advance. During my own training, a colleague had an incredible experience happen doing a social exposure in public. The client was afraid of being embarrassed in front of others and one task for the day was to drop papers in the middle of the large student union at our university. This was a high level on the fear ladder. The client approached the center of the busy room carrying the papers he was to drop. As he began to let them slip out of his hands, a passerby caught them as they fell and placed them back in his hands. On the second round, the same thing happened again. The client was unable to drop the papers! In the end, he was finally able to drop the papers without someone catching them. And, of course, he was immediately assisted in picking them up. In the end, the client’s thoughts and predictions about how people would react to his actions were changed quite a bit. Returning to Savannah’s fear ladder, we can see that the items are mostly practicable in an office setting, though there is one other consideration. How does a therapist create a school presentation experience in an office visit? We manage this in our own setting because we are a training clinic and there are often other therapists and support staff around (or who can be around) to be part of an audience. Knowing that most settings are not like ours, an aspiring exposure therapist will have to be creative. Are there any staff at your site who can join the session as an audience member? Does your agency or practice have a relationship with a local training program (BSW, MSW, psychology, etc.) and are there interns who can be engaged? If not, are you able to create such a relationship? A few cautionary statements about these ideas. First, make sure that whoever you engage as the audience has been properly trained in confidentiality and other important regulations and guidelines (e.g., HIPAA). Second, invest time in preparing the volunteers for what to expect and what you expect. If you want the audience to be supportive and warm (as you often would early on in exposure tasks), be clear about that. If you do want the audience to increase its difficulty, be clear about that too. If none of these ideas can come to fruition, you may still be able to practice public speaking with a client by taking to the streets, cafes, or restaurants. Even though we have a lot of graduate students around to



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assist with exposures, we still rely on our urban setting to assist with social anxiety exposures. For example, we had a young oboist with performance anxiety play songs on a street corner near our clinic. We once had a teenager with extreme social anxiety deliver a brief speech she wrote in a coffeehouse near our clinic. These more public experiences are high-level exposures, since you as therapist have little control over what someone will do or say. There are risks, and thus you will need to prepare a client for those risks and be ready to do some patch-up cognitive work afterward if things go awry. However, the risks are not likely to be greater than when the client speaks in their classroom.

Identifying Exposure Targets for DeSean Next, let’s transition to DeSean’s fear ladder, as it raises a different set of issues compared to Savannah’s. For DeSean, the more intimate social experiences are the ones that generate the most anxiety. That makes things quite simple in the early going for exposures. The therapist themselves will end up being a target for social interaction. That is, many of the early exposures on the fear ladder can be practiced with the therapist. However, and hopefully by design, the anxiety created by the therapist will decrease over time and therefore make the therapist a poor target for exposure practice later for DeSean. So, what do you do in the middle and late phases of exposure? You are in some ways faced with the same dilemma as with Savannah. You must find suitable targets for exposure practice. You have the added difficulty in DeSean’s case of his anxiety being primarily focused on peers rather than adults. Given that DeSean is a young adolescent, adults are not likely to be the best or most suitable targets. Let’s consider a few different ways to approach this challenge. First, let’s take the easiest, though least likely, scenario. If you work in a setting with many therapists around and available to assist for a few minutes; they can be trained to serve as social anxiety confederates. A major advantage to the scenario is that given their training, your fellow therapists can be easy to instruct in how to react and interact with the client. For example, they will know how to increase or decrease their difficulty, even on the fly. Whereas the solution is simple (if available), a weakness should be apparent to you: there is a less than optimal similarity between the exposure task and the actual feared situation. I will return to this problem shortly. Next let’s consider a more likely way to approach finding suitable targets for DeSean. You work at an agency or in a practice where there are no trained therapists available to you for exposures. The good news

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in DeSean’s case is that for the most part you really only need one other person to serve as an exposure target. As a result, it can often be feasible to identify one or two employees at your agency who, with adequate training and preparation, can be a good confederate. In addition to the therapists who work at our clinic, we often rely on our receptionist and our security guard. Almost any reliable person will serve the purposes you need for DeSean, remembering that you need to ensure that that individual understands confidentiality and other regulations as well as their role. It will also be important for you to be able to debrief and provide some feedback for this person. Now, let’s imagine the least desirable situation, one where you honestly do not have access to another person who can serve as a target for DeSean’s exposure tasks. Here, you need to be more creative. The most straightforward approach would be to practice as much as possible of the fear ladder with you as the target and then transition to working closely with DeSean to identify situations in his own life where he can practice outside of your presence. This might involve a fair amount of research on your part to think through with DeSean who would be the best targets for the exposure tasks you are planning. You will also likely need to do some of this research with others in his life, and not just DeSean. That is, DeSean may have either an overly optimistic or an overly pessimistic view of who might be a good target for his practice. Some youths choose more difficult targets because they don’t understand or realize how difficult the person will be. Others are more likely to see all possible targets as impossible and thus be less than ideally helpful in identifying possible targets. As a result, relying on DeSean’s family members or his teachers will be important.

Taking the Social Context into Account Now that I have offered a few variations on how to achieve the targets for your exposure practice with DeSean, let’s turn our attention to a more nuanced challenge with DeSean’s case. The challenge was also present in Savannah’s example, though I did not discuss it because it was more muted there. However, in DeSean’s case, we will not be able to avoid it. I am talking about the subtle nature of social interaction, especially in the wilds of early adolescence. Remember that DeSean struggles with some of the basics of social interactions including greetings, beginning conversations, continuing conversations, and ending them. Most readers are probably relatively adept at these basic social interactions. Most therapists are, because of our training but also because of what drew us



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to the field. We had been told that we were good at social interactions, at making people feel comfortable to talk with us. However, if you were asked to describe to someone else how those basic tasks are achieved, you may find yourself hard-pressed to identify clear rules or guidelines. Further, given that you are now an adult, you will find yourself even more perplexed to identify strategies appropriate for the youngsters of today. I will never forget working with a young teen client on self-presentation skills. This was a depressed young woman around age 15 who tended to present herself in a way that discouraged others from interacting with her. We discussed the benefits of this approach, as well as some of the costs. She did not often get the opportunity to interact with others because of her cold demeanor. As we discussed this topic, we assembled a list of what we referred to as “presenting my best self” skills. She was quick to let me know that she could not and would not present herself as one of those “perky cheerleader types.” That was not going to be her style and she did not think that her peers would find that approach palatable. Instead, as we practiced her presenting herself more negatively and more positively, I noticed and remarked upon how subtle the difference was between the two. Both were low key, what she called “chill.” The main difference was in the content and the amount of information that she shared. When she was being her more positive self, she shared information that was more positive and upbeat and she definitely shared more of it. Thus, in her mind, the difference between presenting herself optimally and in a positive light was subtly different than when she was presenting her more depressed and less positive self. I often tell this story to my trainees when working on social anxiety exposures that involve basic social interactions. As I will discuss in more detail in the next section of this chapter, social skills are subtle and highly contextual. That is, they are difficult to teach with a lot of specificity. Even with reasonable instructions, you are likely to have to adapt and sometimes even outright change them depending upon the context. By context, I mean the situation in which the interaction is occurring, including the place, time, who is there, the moods of the people interacting, and so on. For example, imagine having a conversation with your supervisor’s supervisor at a formal event and compare that to a conversation with your best friend out at a concert with your favorite band. You may display excellent social skills in both of those situations but they would be quite different from each other to anyone observing you. To return to DeSean, a good rule of thumb is to help prepare him for a variety of social situations and to do so by encouraging variability

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in his approach. That is, for most clients, stay away from teaching a specific script and instead focus on some principles to follow. Take something simple, like greeting someone. Notice that some of the early items for DeSean are at this level, saying “Hi” to people he knows or ones he does not know. It will be important in practicing with DeSean to think through how one might actually do a greeting with individuals in his life. Some people actually do say “Hello” or “Hi.” Others use phrases like “How are you?” or “What’s up?” or “Hey!” Sometimes subtle gestures are used, such as a head lift or a hand motion. Obviously, for exposures with DeSean, you will emphasize verbal production. However, you want to be aware that the specific words he uses are less important than that he learns from the social interaction and adapts to what is typical for the context. A good way to do this can be to give to DeSean the homework of observing how students in his school greet each other in the hallway in between classes. He can act like an anthropologist and bring back his findings about his fellow students’ greeting behaviors. This can be good fodder for helping DeSean understand that there are many different ways that people say hello and thus that there is no one correct way to do so. Such an assignment works on multiple levels. Many anxious youth are perfectionistic and assume that there is a right or correct way to interact socially or to do anything, for that matter. As a result, by helping DeSean see that there is great variability in greetings, you can do some subtle cognitive work on his belief that there is a right way to do it. Second, it helps you as the therapist to understand his context better and to interact with him in a way that will have more of what one of my creative writing professors called “verisimilitude”—that is, it will feel more real to DeSean, ideally leading to more generalizable outcomes. Working through the rest of DeSean’s fear ladder involved a variety of commonplace social skills that he can practice in almost any situation. Starting conversations, maintaining conversations, and ending conversations all appear to be important targets for exposure in his case. It is simple to imagine implementing exposures with the therapist or others at the agency. Social interaction like this is easy to replicate. However, enhancing the verisimilitude of these interactions will quickly become an important goal in most cases. DeSean may well become adept at starting, continuing, and ending conversations with highly trained mental health professionals, but he may still struggle with his peers. As a result, it becomes your job as therapist to determine creatively how to help DeSean practice the skills with people his own age. This can occur in a few different ways.



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Although unlikely, you may work in a setting that would permit you to have DeSean interact with other clients at the agency. In most agencies, there would be strict rules against this kind of activity. However, in some settings, there may be some flexibility built into confidentiality forms that a client signs that may allow for clients with similar problems meeting for the purpose of exposure tasks. As those familiar with the research literature on social anxiety treatment for children and adolescents know, group treatments that use exposure are common and effective, for obvious reasons. A group provides built-in access to social anxiety exposure targets. If you happen to be in a setting that permits clients to interact with each other (or can make arrangements to permit it), then obviously arranging for social exposures with same-age peers becomes relatively easy. I will assume that most of you are not in such a setting and are unable to create the arrangement. There are other options to consider. One option that we have used in our clinic is to engage college or high school interns specially trained to serve as exposure confederates. These are high-achieving students who have come to us in search of work experience and/or class credit via service learning or practicum experience. One of the ways we help them understand what life as a mental health professional would look like is to involve them in exposures with clients. College-age students are closer in age to someone like DeSean than we are. High school students are even better, though they will likely require more training. In our clinic, we happen to have a standardized training approach that orients our interns as well as our therapists to the relevant ethical and legal requirements and guidelines. If you think you can arrange this sort of setup, it can be quite useful. The interns are relatively easy exposure targets, though a bit tougher than the typical therapist. Remember: therapists tend to be among the nicest and kindest social participants, making them often the easiest person to interact with that a client may encounter. Interns, on the other hand, are doing their best to be easy but they do not have the same experiences and training as mental health therapists. As a result, some of their gaps and gaffes are actually opportunities for the client to do important learning. Perhaps you don’t live in an area where you could easily access college or high school students, or your agency does not have a way of doing that, or it just seems too risky to you. OK, so what can you do? Well, you have to go into the wild! And by the wild, I mean the client’s actual life. You will have to develop a deeper understanding of the social possibilities in the student’s current life and then plan for them to practice. Let’s walk through a few of the necessary logistics.

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First, you’re going to need an informant or two. You need someone who can provide supplementary data for you about possible social targets in the client’s actual life. You will go to the client first. The client is, in almost every case, the best source for the full range of social targets available. However, clients are not always the best judge of the appropriateness and/or availability of a given target. That is, sometimes the client can aim, with all the best intentions, at a target that would not be a gradual step from the previous exposure task. Sometimes, the client may want to take a big leap instead of the small one we are looking for. As a result, you will need an informant, such as a parent, caregiver, teacher, or coach—someone who can provide additional information on the choices the client has for possible social targets in their life. Once you have your informants, you then assemble a list of targets, arrange the items hierarchically, and generate your tasks. Depending on your setting and what is possible for you in your practice, you can either prescribe exposure practice sessions for the client to do on which they will report back or you can meet the client in the setting in which the exposure practice will occur and arrange to meet with the client in a private space once the client has completed the interactions. Obviously, the latter has great advantages in terms of getting fresh information and even in assisting the client to engage in multiple trials for the same exposure target or set of targets. However, meeting the client out in the community can be a challenge for some folks. In those cases, the best we can do is to clearly articulate and write down the expected exposure tasks and then ensure that we follow up at a minimum in the next session and potentially in a quick phone and/or e-mail exchange. There is some preference for contacting the client immediately after the task is completed in order to better understand the client’s feelings and reactions in the aftermath versus several days later once many intervening events have occurred. We have completed a walkthrough of how we might implement exposure across the two different fear ladders of Savannah and DeSean. In the next section, I focus on a key topic: identifying the specific drivers for a client’s social anxiety so that we can design the most appropriate exposure tasks.

Toward Clarity about Social Anxiety Drivers Social anxiety is an easy experience with which to empathize. Most of us experience some level of social anxiety, at least in high-stakes social



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situations such as job interviews or romantic interactions. Indeed, social fears can be among the easiest fears with which to relate. As a result, one challenge for conducting successful social anxiety exposure can be overcoming your own assumptions about what will make a particular social situation challenging. Although social anxiety is ubiquitous, common, and easily relatable, it can also be quite idiosyncratic. A key then becomes developing a strong understanding of the drivers to a particular client’s social anxiety. I offered some pointers on the importance of drivers, or why stimuli are feared, in Chapter 3. Here, I will focus on how what kinds of drivers may be relevant in social anxiety cases. I have a colleague who commonly uses an example (referenced earlier in the book) that makes the point about identifying drivers clearly. Imagine designing exposures for a client who fears going into the bathroom at their school. Unless we know why they are afraid, we can easily go down the wrong path. In trainings, we often ask folks to identify different reasons that a client would fear the bathroom. Hygiene is often the first one people identify; bathrooms are dirty and therefore one might fear illness that can be contracted in them. Apparently, mental health providers value cleanliness in the restroom. Another is fear of others hearing you use the bathroom, the so-called shy-bladder syndrome. One might fear the bathroom because of other potentially unpleasant social interactions that can occur there, such as teasing unrelated to doing one’s business. The bathroom is a private place away from adults and some children use that opportunity to belittle their peers. Alternatively, one might fear the bathroom because it is a small place from which escape is often limited to a single door. What if I had a panic attack and needed to escape? Or, one might have had a traumatic experience in a bathroom and thus entering one brings back a cascade of memories. In short, there are a lot of reasons one might be afraid of bathrooms. Understanding which are active for a particular case will facilitate your appropriate selection of exposure tasks. Let’s consider this idea in light of the cases of Savannah and DeSean. As the therapist learned from assessment (Chapter 3 discusses the how in some detail), Savannah’s social anxiety is driven in part by an internal aspiration to be excellent at everything. She has high internal goals for herself and is consistently seeing herself as falling short of them. As a result, performance situations are anxiety-provoking for her, as she worries that she will perform badly and thus fall short of her goals. She wants to perform well, as judged by standards set by teachers and other authorities. In other, less structured social situations, such as with peers, she has much less anxiety. She does not view those situations as

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performance-oriented and she does not see her social life as a milieu in which to excel. As a result, with Savannah, the therapist found opportunities to address Savannah’s underlying thoughts about her own performance. On the one hand, the therapist helped Savannah see her performance more objectively—to identify how she did well and how she might improve. They also focused on noticing then Savannah’s perfectionist voice intruded into her mind, something that happened a lot early in treatment. And they developed a way to talk back to that perfectionistic voice; for Savannah, thinking to herself “I am learning” or “I am doing my best” were simple yet helpful thoughts to calm the perfectionistic fires that would rage at times. On the other hand, the drivers at play here also led the therapist to help Savanah focus some of her attention on how her school performance was perceived by others. Most of the time, she received praise for her work, feedback she tended to ignore or discount. Her therapist helped her to consider the feedback more carefully and to imagine what it might feel like if the feedback were indeed true. Thus, the therapist emphasized seeking and evaluating both internal and external feedback. DeSean’s social anxiety is driven by his lack of confidence in his interactions with others across many social situations. His concerns are mostly focused on whether others will like and accept him, with an expectation that they won’t. Similar to Savannah, he worries about his performance. However, in his case, DeSean believes in an unspoken standard in unstructured social situations, a standard that he fears desperately that he will not meet. With DeSean, the therapist used the analysis of the drivers to focus strongly on helping him seek out information from the social world rather than from his own internal experiences. Consistent with research that suggests many individuals with social anxiety have an overly intense focus on their own internal experiences, especially physiological ones, the therapist helped DeSean become a detective concerning his social world. They gathered evidence on how people acted toward him, focusing on their behaviors and their words (rather than guesses about what they were thinking). As treatment progressed, this focus was helpful in that DeSean began to notice that his peers responded to him more positively than he had thought. As one example, the therapist helped DeSean realize that a kid whom he thought did not like him because he complained to DeSean about the teachers was actually trying to be his friend. Clearly, then, an assessment of the reasons that drive the social



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anxiety of your particular client are well worth the investment of time. I turn next to another important assessment: the client’s baseline social abilities.

Assessing and Addressing a Client’s Social Skills Just because a client has social anxiety problems does not mean that they have poor social skills. I have worked with many clients in our clinic, both children and adults, who have social anxiety disorder and whose social skills are at least fair, with some even having good to excellent skills. Social anxiety disorder is not necessarily one that stems from or causes poor social skills. However, it is understandable that someone with social anxiety disorder would sometimes have rusty or poor social skills. After all, for us to improve in any skill area, we must practice. Clients with social anxiety disorder have less opportunity to practice their social skills because they tend to avoid social interactions. Clients whose social anxiety disorder has been long-standing tend to be the ones with the worst social skills. One of your first tasks will be to determine how strong the client’s social skills are. Let’s consider a few of the basics. DeSean’s case is a good example because many of his areas of concern were related to basic social interactions. For the purposes of this chapter, I will focus solely on the following domains: greeting, starting conversations, maintaining conversations, and ending conversations. There are obviously many more facets to social skills; for more in-depth information, consider these excellent books: Bierman and Greenberg, (2017), Frankel (1996), and Laugeson and Frankel (2010). The goal in this section is to provide some tips on how to assess and then address a few basic social skills that if lacking can be ameliorated through practice. First, a reminder: social interaction is highly contextual (like most of human behavior). There are no rules or universal laws. One of your jobs as a therapist is to understand, assess, and adapt for diversity of all kinds. The assessment of social skills is a challenge for a few reasons. First, as I have made clear throughout this book, social skills are highly contextual. Some clients will have excellent social skills with you but dreadful ones with peers; others will be vice versa. You can generally identify the latter in your first sessions. The client may have trouble stringing together sentences with you or may engage in monotone soliloquies. They may demonstrate nonverbal social skills deficits like limited

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or too much eye contact, extreme fidgetiness, and/or other behaviors that detract from social interaction. These cases are the easier ones to notice regarding social skills deficits that need to be remediated. The subtler cases are those where the client is adept with adults but less so with peers. We hope the caregiver can shed light on this problem early on. In social anxiety cases, it can be helpful to engage teachers in your assessment process as well, as they are often able to provide the kind of data you need. Some clients in this category are bright and verbal; they do better with adults, as their peers tend not to have conversations that contain a lot of $100 words. Other clients in this category are easily intimidated or “hurt” by peers’ social interactions and prefer the safety of adult interactions, as they tend to be less “rough.” Either way, once you know about the deficits, you can address them. As I have tried to make clear, social skills and social interactions are complex and mercurial. As a result, it is wise as a therapist to have appropriate respect for the limits of our expertise in how best to help clients with social situations. Alas, therein lies one of the many challenges of our chosen field. With these caveats in mind, let’s turn to how we might intervene to improve social skills. First, consider the beginning of any social interaction: the greeting. Two people see each other and acknowledge that they have seen each other before and know each other. I covered some variations of greetings earlier. A goal in assessing and practicing greetings with a client is to avoid thinking that there are is a right way to do it and instead focus on experimenting to find the ways that work in different situations. Adults tend to like more formal greetings, such as “Hello” or “Good to meet you,” whereas peers tend to respond better to more informal approaches such as “S’up” or “Hey.” Encourage the client to enter an experimental mode wherein they test out different approaches and sees which work best for them in different situations, much like we might try on different outfits to find the one that works best for us, knowing it won’t be the only thing we wear for the rest of our lives. Obviously, this experimental and flexible approach models for the client how they might approach many daunting situations: not as entrance exams that will determine the rest of their life but rather as another situation in which to learn and keep getting better at doing stuff. Greetings, like a lot of social interactions, also create opportunities for the therapist and the client to engage in observational research. For example, you and the client can go to a public place and observe how others greet each other. Take notes. Notice the variety in how people greet each other. Hand gestures. Nods. Hugs. Words. So many different ways to greet, further underscoring the point that there is not a right way



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to do any of it, a point that is important for the client (and for some of us therapists too). Greetings can lead to the start of conversations, the next domain of social skills to assess and, if needed, remedy. Even more so than greeting, the skill of conversation starting is idiosyncratic, since there are nearly an infinite variety of topics for conversations. If a client is lacking in the skills needed for the early stage of conversations, the good news is that these are easy to practice. Suggestions for conversation starters abound in books and on the Internet. You can also practice conversation starting in sessions to improve the client’s skills. Again, you can encourage observation by assigning interesting homework like watching television shows or eavesdropping at school or in social settings like malls or football games or church to see how other people start conversations. Last, we turn to maintaining and ending conversations. These related skills are even more nuanced than the beginnings of conversations. However, there are some basic strategies that many young clients have not yet learned or mastered at which most therapists excel. For instance, you can share the wisdom that most people like to talk about themselves. As a result, one way to keep a conversation going is to ask questions about things the person likes. You can practice these sorts of questions across a variety of topics. A related skill is that of active listening. Sound familiar? You can help a client learn how to listen to what someone is saying and then rephrase just a bit of it to ask a question or for elaboration. “Sounds like you had a good trip to Washington. What did you like most?” Another skill is related to body and face posture. Looking in the direction of the person and nodding periodically goes a long way, as therapists reading this book well know. The well-placed “Mm hmm” and “Yes” also help move things along. Of course, so far we have emphasized continuing conversations by drawing the other person out more. That is, how to keep the other person talking. Many socially anxious people prefer this style of conversation, as they do not have to open themselves up to scrutiny by saying much. Your job is to teach and practice the other side of the game with them too, helping them to start sharing about themselves. In the beginning, it may help for the client to have a few go-to topics that they share that tend to lead to easy and positive conversations. Those topics are highly individualized, of course. For many kids, however, complaints about school or a particular teacher can be an easy starting place. Pop culture can also be mined, though I strongly caution therapists from making suggestions here; coolness is supremely ephemeral. In short, don’t bother trying to know what is cool. Look to the client and their

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research to help guide you. To strengthen the client’s skill with talking about themselves, you can start with exposures that require responses to a small and set number of follow-up questions on a particular topic: math class, gym class, the upcoming dance, the movie you just saw. Then you shape longer, more elaborated responses. You need to ensure there is a back-and-forth here. Conversations do not usually work well if they are one-sided. However, there is no formula for how to script it out. For socially anxious clients, you tend to emphasize staying in the conversation long enough for anxiety to decrease. Remember that the ultimate goal is habituation. I also have to talk about the skill of ending a conversation. For me, this is the most difficult skill to teach because it is pure nuance-city. So many reasons can drive the end of a conversation: an upcoming appointment or engagement, a sudden need to pee, a strong hunger, the draw of a friend from across the room, an interruption, a text message that blips in and pulls someone’s attention away, simple fatigue with the social interaction. When you talk about this skill with clients, emphasize a few key ideas: (1) conversations end for many different reasons; (2) the overwhelming majority are not an indication of how much one person likes the other; and (3) there are subtle and not-so-subtle signs that people give when they are ready to stop the conversation. All three of these lend themselves more to assigning observational research to the client than to practice, though you should always practice too. You can practice how to leave a conversation using different strategies and you can practice facilitating someone else ending the conversation. I have one more general point about social skills drawing on work in our clinic and research on social anxiety and selective mutism. My colleagues and I have worked with a number of selectively mute clients, whose social anxiety is off the charts and whose only early exposures are for making greetings and starting brief conversations. For these cases, we developed a set of what we called “facets” (like a diamond), representing aspects of social interaction that we could gauge and about which we could provide feedback to the client. The facets were (1) eye contact, (2) body posture, (3) voice volume, and (4) speech clarity (i.e., how clearly one articulates). We used the facets as a feedback tool, letting the client know how they were doing on each. Full-on eye contact may not be preferred in many situations, though some adults (e.g., teachers) may require it. Ditto with body posture. The client can be shaped to use those skills as needed. The goal is to loosen the client up, to help them to see that flexibility is an important attribute for social success.



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For the last section of the chapter, I turn to the challenges that arise from social exposures. For the most part, social exposures are the riskiest ones in practice, as the therapist has much less control over the stimulus than with most other exposure tasks. This is especially true once the exposures have transitioned into the client’s daily life.

Troubleshooting When Social Situations Go Awry Tolstoy famously wrote, “Happy families are all alike; every unhappy family is unhappy in its own way.” Let’s extrapolate that statement to social exposures. When they go well, there is little uniqueness. Savannah delivers another presentation, this time with a bit more skill. DeSean introduces himself to yet another person and this time he is able to do a little variation on his monotone delivery of “Hi. Nice to meet you,” even adding a comment about the person’s cool t-shirt. Exposures that go well keep the client and the therapist happy, maintaining the “lather– rinse–repeat” pattern. When things go off the rails, though, they do so for myriad reasons, only some of which can be predicted. This brief section will focus on two particular varieties of social exposures gone wrong: (1) when the social experience is negative and (2) when the client refuses to engage. There are many other ways for things to go badly. However, these represent two of the more common ways.

The Social Experience Is Negative I begin with the more difficult of the two: the exposure gone wrong. First, I offer a few examples. Consider Tyler, a socially anxious middle schooler whose task late in treatment was to introduce himself to a peer at school. His first attempt went well. He sat a lunch table with a peer he knew from class and introduced himself casually enough (or so he told us). However, more peers joined the table and Tyler felt overwhelmed by the situation, so much so that he fled as soon as he could, having barely eaten his lunch. Also consider Ava, a 10th grader whose assignment to give a presentation in class went badly from the start. The technology for the presentation did not work; the teacher was described as unhelpful and mocked her for not knowing how to get the projector to work. By the time she did get started, she was so flustered that she raced through her talk breathlessly, to what she perceived as the confused and bemused faces of her classmates. Finally ponder Lucy, a ninth grader who had

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recently moved to a new school in a new state. When assigned to get to know two new peers at school, she opted to start with a classmate with a reputation (she later learned) of being the meanest of the mean girls at the school. What started off as a casual “Hello,” in the hallway between classes ended up as a bald-faced rejection by the girl with what Lucy perceived as dozens of giggling onlookers. “You are talking to me?” was a quote she shared. I can feel most readers’ guts tightening up with empathy as they read about these challenges. We have all been there. The social situation that starts with promise but crashes and burns. Imagine being the therapist who assigned the task? Imagine facing the client in session the next day? Well—if you are reading this book, that could (and will, I hope) be you. There are several pieces of good news to consider when facing this kind of bad news from your client. First, although I would never say it like this, these experiences are a good “welcome to life in the social world” moment. That is, you can make the psychoeducational point that social experiences are by their nature variable because people are variable. And that variety is both across and within individuals. In other words, each person will be unique to interact with. That is great news, since if things did not go well with person A, they may go great with person B. Furthermore, even the same person can vary a lot in terms of friendliness and receptiveness over the course of the day, the week, or the month. And this is true not only for people but situations too. Ava’s experience with the projector is a nightmare most of us have had to muddle through. All kinds of things happen. Just because Ava had a bad experience with a projector and an unsupportive teacher does not mean that all of her presentations will proceed the same way. The next time can be a total reset. Lesson one from these tough exposures is a psychoeducational one: the social world varies, so we keep trying. Next, it is time to engage in some reflective problem solving. Here, we work with the client to dig into the situation deeply and consider what steps could have been taken to reduce the lousiness of the outcome. It is important to monitor for self-blame when taking this step. However, the risks there are outweighed by the potential for fostering future-oriented thinking and planning. Learning from these tough experiences can be some of the most valuable learning we do. It can be useful sometimes for a therapist to reflect on their own tough experiences and how they learned from them. Often, there are steps we could have taken had we known better how the situation would unfold.



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Let’s return to Lucy’s situation of selecting as her first exposure the queen of the mean girls. As a new girl in the school, she did not have a good grasp about the social situation and the status hierarchy. Now, with the tough experience under her belt, she had gained the hardearned wisdom that scoping out the social milieu is a good idea. She and the therapist spent the next few sessions engaged in some detective work, trying to gauge who would be a good person to choose for the next task. This involved two steps. First, they looked back on the friends she had at her past school. What were they like, how did she make friends with them, how did she know they were good to approach? They also gathered data in the present. They spent session time pondering different kids at her new school and how she would know if they might be a good person to approach. After a few sessions of hesitation and resistance, Lucy was able to identify a few kids who reminded her of her friends at her old school. By the third session, she brought back the first of what became a slew of more positive reports as her efforts took hold in the new social world. In the end, the two steps of looking back and gathering data in the present helped Lucy fend off the conclusion that everyone would hate her at the new school. Many times, the gentle exploration of how one might prepare more fully the next time is a successful path. Other times, it is not sufficient in part or even at all. In addition, even when the first two ideas provide some help, they are not enough. One of the most important strategies for these tough situations is doing some cognitive work to reframe what has happened and to consider that the client might come to accept it, or at the least come to terms with it. Let’s take a few moments to consider how we might use a powerful cognitive intervention when social exposure goes awry.

Cognitive Strategies When Exposures Go Awry Helping to frame the situation in the client’s thoughts is an important step. And there are a few key framing points to make. The first: the client survived. This is not a small point. You can lift the client up by noting that they faced a really tough situation and made it through. It did not go as well they wanted, but they made it. Take Tyler’s situation. When things escalated at lunch, he hung in there for a long time before he left. That “muscle” he used to hang in there got stronger. And if he keeps using it, that muscle will get stronger still. The focus is seeing the situation as evidence of the growing coping power of the client. With the coping awesomeness of the client affirmed, the cognitive

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focus can next turn to rooting out misperceptions about the event. Life moves pretty fast and we are rarely able to observe it as carefully as we might like to as it rushes past. Remember learning about the two tracks of thinking (i.e., the implicit or fast system and the explicit or slow system) in college or graduate school? That implicit/explicit distinction is present in a lot of human activities beyond thinking (e.g., emotion, behavior). These two tracks, well explained in the book by the Nobel Prize recipient Daniel Kahneman (2011), represent a key finding from the science of psychology: we are capable of absorbing a wealth of information but that much of what we sense is not processed thoroughly (or at all). Our automatic processing system alerts us when something important happens. Otherwise, we focus our conscious processing system on the task at hand. When we are anxious, we often focus that conscious processing system on threats we perceive, at times by exaggerating them. And we often miss more positive signals in the environment. So, the second cognitive step is to go back through the situation and consider how the client has reconstructed it in their mind. What do they remember? What might they have missed? And what are their attributions about those elements and what is the evidence for those attributions? Let’s take Ava’s presentation first. The technology was not cooperating and she said the teacher mocked her inability to get it working. Ava and her therapist walked through the painful memory to understand better how Ava knew the teacher mocked her. It turned out that the teacher had said, “This projector was just working yesterday,” a statement Ava interpreted as meaning that Ava had broken it. Ava and the therapist were able to generate other possible meanings for this statement from the teacher, including that she may have been puzzled by it not working today or even concerned that she herself had done something to cause the projector not to work. Ava still believed her initial impression was most likely, but her mind was opened to that conclusion not being the only possible one. Further, recall that Ava perceived that the other students were confused and bemused by her presentation once it started. Again, the evidence for the conclusion was weighed. Ava and the therapist had a funny dialogue about how they each remembered being in the audience when a classmate in high school was giving a presentation. When you are not in the spotlight, it is easier to look around and see what the other students are doing. And both Ava and the therapist agreed that most students are pretty checked out during other students’ presentations. Further, Ava reached the conclusion that there was probably a



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range of reactions to her situation, from the confusion she perceived to be empathy at how tough it was for her and relief that she was going first and thus getting the technology thing solved before the next student got up there. This quick survey demonstrates how cognitive interventions may be used to cope with a tough social exposure. Next, I discuss how to proceed in one of the most challenging situations for a therapist: when a client refuses to engage in the exposure task at hand.

When the Client Refuses As I made clear earlier in the book, refusal is the name of the game for most kids with anxiety. Their lives have often been filled with refusal to do things they perceive as scary, followed by adults’ efforts to encourage them. Here, I am not talking about the garden variety of refusal. In Chapter 4, I described Leila, the 9-year-old girl who was afraid of many things and whose first exposure with me involved her crying in the lobby in front of an elevator. Her tear-filled refusal could have swayed me to stop and let her avoid, as most adults had allowed her to do in the past. Instead (and with plenty of self-doubt), I had faith in exposure and faith in the power of that little girl. I waited her crying refusal out a few minutes. Shortly, we were riding the elevator and her confidence grew. That example is what I consider normal refusal. It is not a surprise that clients will be hesitant to engage in exposures. As an exposure therapist, you learn to wait that sort of refusal out and encourage forward motion. Instead, I am talking here about a situation where the client is frozen and truly scared. These situations are difficult because they require you to make a call in the moment: Is the client petrified or merely afraid? Are we in the danger zone or one of the tougher areas in the learning zone? The latter means you wait it out and insist on engagement. The former, though—that is when you have to head down the path we have called in our trainings “stepping back without backing down.” The client has been rewarded for avoidance through anxiety reduction and often social rewards. We are battling the tide that pushes the client to avoid. As a result, even when the client is at a 9 or a 10 on their anxiety rating, therapists work hard to prevent pure avoidance. That is why it is almost never acceptable to push the eject button on the task and call it a day. There are basically three paths to consider. Path 1 is

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to slow things way down but keep going. Path 2 is to dial the task back to one that is still tough but easier than the one the client is facing presently. Path 3 is to have a brief coping huddle, regroup, and then reselect the exposure task for the day. Let’s look at each of these in more detail.

Slow Way Down Path 1 involves slowing but not stopping. An easy way to understand this is to imagine you are riding in a car that someone else is driving. The speed of the car is frightening you, so the driver slows down some. They don’t stop and get out of the car. They don’t stop and switch to bikes. They keep driving, just more slowly. Let’s return to DeSean from earlier in the chapter who had fears about talking to new people across many situations. One set of tasks on his fear ladder involved asking questions of employees at a local supermarket, such as where certain items are kept or where the restrooms are located. At the first trial, DeSean started to balk, looking really scared, and said, “I can’t do this,” as he and the therapist approached the first employee in the cereal aisle. The therapist said quietly, “We’re walking pretty fast. Let’s walk more slowly and take some deep breaths as we get closer.” She also made some observations about the employee they were approaching, noting her apparent age and hair color and demeanor. These steps slowed things down enough for DeSean to gather himself. Notice the two things the therapist did here. First, she slowed the situation down literally by moving more slowly. Doing so serves the purpose of de-escalating a person physiologically. Moving slowly is associated with being more relaxed. Remember back when you learned about the autonomic nervous system and how the sympathetic and parasympathetic nervous systems balanced each other. Here, the therapist leaned into the parasympathetic nervous system. Second, she brought DeSean’s attention away from his internal experience and toward the social stimulus. Bringing awareness away from themselves is often helpful for socially anxious individuals. As I noted earlier, research suggests that such clients’ attention is often overly focused on their own internal experiences, including physiological ones. Attending to the outside world can be a useful way to test out thoughts or guesses one has about the situation. As DeSean approached the employee, the therapist asked questions about the person to focus him on the actual stimulus and to address any expectations that DeSean might have. Yes, the employee has a name tag. And yes the employee is



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working on something. And no the employee is not frowning but is in fact looking at us and beckoning us over. Sometimes, though, slowing your roll on the way to an exposure that has stopped a client in their tracks will not work. That is where path 2 can come into play.

Make the Task Easier As noted earlier, in Chapter 4, an important attribute of an exposure therapist is the ability to dial a particular exposure up or down depending on how things evolve. Recall that rating the challenge of a situation in the abstract is often an exercise in inaccuracy. As a result, when embarking on a particular exposure task, it is wise to have several more difficult and less difficult alternatives in mind so that you can adjust the task on the fly. Thus, if the client balks at the planned task, you have an alternative in mind. Changing to the alternative path requires some important steps. First, you will note the difficulty of the proposed task. “Wow—that was a bit harder than we had thought it would be!” Obtaining the client’s rating helps cement the impression. Assuming you have tried to go with path 1 and the client still remains fearful and unwilling to proceed in a manner that goes beyond garden-variety resistance, you next note that the plan had been to pick an item that was at a somewhat lower level of difficulty than this one turned out to be. Next, you engage in some quick discussion of the alternatives you have already identified in your mind. Presto change-o, you have a new exposure task and a new baseline rating for the original one. Path 2 was trodden a few times in Savannah’s case. One of her early exposures was to give a brief speech to a group of three therapists at our clinic, including her own therapist. The topic was one she knew pretty well: how to use Snapchat. Her initial rating for this task was a 4/10. However, she had had a bad day at school and was upset coming into the session because she had taken a test and felt it had not gone well. As they prepared for the speech, Savannah was almost tearful and asked if they could do the speech next time. Determining that Savannah was truly upset and could also benefit from a success, the therapist offered a compromise: do the speech but with only one other therapist in the room. Savannah was initially reluctant, but as they wrote out the speech on index cards and practiced it a few times with the therapist alone, taking ratings along the way, she agreed to give it a try. The two therapists

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learned a lot about Snapchat that day and Savannah learned she could back up without backing down.

Coping Huddle, Regroup, and Reselect the Task In the above example with Savannah, the therapist also had to head down path 3. Path 3—taking a big step back and engaging in some coping skills—is the third option because an important higher-order goal of exposure is to help the client learn they can handle their anxiety, even when it is intense. Pausing to engage in coping skills may seem like an acceptable path. And it can be. However, the pause is itself avoidance and even careful therapists can watch a brief pause turn into a longer one. Think of it as a slippery slope. As long as you get back up pretty quickly, you won’t slide off the trail. There are definitely situations when a pause to cope is needed. This is particularly true when the client is so upset that they cannot talk or think clearly. Recall again our friends the sympathetic and parasympathetic nervous systems. Once activated, the effects of the sympathetic nervous system can linger and interfere. A rigorous activation of the parasympathetic nervous system is sometimes in order. Relaxation and cognitive strategies are the most common ones we use on path 3. (See Chapter 5 for many more details on coping skills.) Taking some deep breaths and even engaging in a brief guided meditation or a mindfulness activity can help to right the ship, allowing the client to move back toward the exposure task. That is the key to path 3 and why it can be a slippery slope. Take an upset client, add a caring therapist who finds that some coping skills are reducing the client’s distress, and you have a recipe for a reinforcement double feature where both parties are reinforced for avoiding the exposure task. Hence, your job is to keep your eye on the long-term goal of reengaging in the exposure. It is useful for the client to learn that they can calm themselves down when upset. It is more useful for them to learn that they can handle a frightening but nondangerous situation. My goal with this chapter was to prepare you for some of the logistical challenges raised in doing exposure with social anxiety. A common theme, though, with all problem areas is the importance of helping the client to learn that doing things that feel scary and are not dangerous will get easier each time they are done.

CHAPTER 8

Exposure for Separation Fears

I move next to fears related to separation from a caregiver. These fears may be related to either the child’s concerns about their own safety, concerns about the safety of the caregiver(s), or both. Although exposure with these sorts of fears draws strongly on the basics I have outlined, the variations are more extensive than some other problem areas in part because there is nearly always intensive involvement of caregivers throughout. I begin with a brief description of the problem area.

Description Separation anxiety plays an important role in the development and adaptation of humans. There is a normal peak of separation anxiety around age 18 months, when toddlers begin to discern that the caregivers to which they have grown accustomed disappear from view for hours or sometimes even days at a time. This early separation anxiety generally wanes through the repetition of separations and reunions, events that happen in most caregiving situations quite regularly. Although for some children the separation fears can become exaggerated and/or impairing, for most children separation anxiety at this age is anticipated and normative. In short, when toddlers exhibit separation fears, they rarely rise to the level of true clinical concern, even when caregivers may believe they do so. For some children, a second period of normative separation fears may occur around the time the child is introduced to routine schooling, either in preschool or in kindergarten. There is quite a bit of variability 135

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about when these out-of-home arrangements begin. National data suggest that up to 40% of children under age 5 with employed mothers are in some form of out-of-home child care arrangement. All children nationwide are required to enter school at age 5. The transition from a life mostly at home in the care of family members or primary caregivers to a life with a significant portion of time spent at some out-of-home location (e.g., day care, school) is often characterized by acute episodes of separation fears. Typically, these fears peak in the first week or two of the arrangement and subside with the repetition of the separation– reunion cycle without any formal intervention. In the case of schooling, there can be flare-ups of the fears after vacations away from school. In general, though, it is around this second period of normative separation fear that we are most likely to see a shift to problematic separation anxiety. But what exactly does that mean? From a diagnostic perspective, I am talking about separation anxiety disorder (SAD). SAD is a common disorder, with a prevalence estimates ranging from 4 to 5% in epidemiological studies. Age trends typically find higher incidence rates in early and middle childhood, with declining incidence as children enter adolescence. Because SAD often leads to family conflict and/or academic problems (e.g., missing school), the diagnosis is common among youth referred for treatment. In some ways, exposure with SAD is straightforward. For most cases, the situations that provoke fear are clear and easily practiced. Further, in most cases, there are relatively easy-to-identify coping skills that may supplement exposure, including relaxation and cognitive strategies. However, there are some important wrinkles to exposure with SAD and I focus on those here. Most variations center on involvement of major attachment figures: (1) involving caregivers, (2) assessing and addressing caregiver versus client fears, (3) caregiver conflict, and (4) child fear versus child perceptiveness. In addressing these points, I also cover two common challenges encountered in treating children with SAD: (1) school refusal and (2) co-sleeping.

Involving Caregivers Involving caregivers in treatment of child and adolescent anxiety is a necessity in many cases. At a minimum, the caregiver will almost invariably be the person who identified the need for treatment, who transports the child to the sessions, and who is paying for the treatment. These basics are present for almost all child therapy. However,



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the need to involve caregivers in exposure therapy for child anxiety goes well beyond these logistical issues, especially with separation anxiety. As discussed in Chapter 3, the assessment chapter, caregiver involvement is critical in developing a fear ladder. Often, a child client is unable to identify and provide valid ratings for items on the fear ladder. The need for caregiver involvement in fear ladder development is particularly poignant in the case of separation anxiety because of the nature of the problem. The basic fear here concerns the caregiver themselves. As a result, fear ladder development will involve careful assessment of items and their fear ratings for the client and for the caregiver. I will cover that latter point in more detail shortly. Caregivers are also needed in treatment of separation anxiety because they are often a required “stimulus” for exposure. Items on the separation-anxious client’s fear ladder often involve the caregiver in some way (their proximity, their responsiveness). For example, the following fear ladder items require active caregiver involvement: • The caregiver is not present in the session. • The client leaves the office with the therapist but without the caregiver. • The caregiver leaves the office during the session (i.e., is not in the building when the session is being held). • Analogues to home-based scenarios that are challenging (e.g., being out of eye contact with the caregiver, bedtime scenarios). Note that these examples only include fear ladder items involving in-office exposures. A related, and important, way that caregivers are needed in treatment of separation anxiety is in their role as cotherapists due to the frequent need to engage home-based exposures. Although some of the typical separation anxiety fear ladder items are practicable in an office setting, many if not most must be conducted in the home setting for optimal effectiveness. If a client is afraid to be alone in their room, one can practice in the office; the real test, though, must come at the client’s house. The stimuli associated with the fears are all missing in the office environment. For those therapists who can conduct homebased sessions, managing these home exposures is relatively easy. However, for those who cannot do home-based work, your relationship with the caregiver becomes paramount, because much of the critical work will happen on their watch and under their gaze. The need for considerable caregiver involvement means that

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building a strong and collaborative relationship with the caregiver will be some of your most important work with separation anxious clients. The basics involve establishing clear and trusting communication, relative agreement about treatment goals, and a strong foundation in how to implement exposure.

Teaching Caregivers to Implement Exposure An important role for therapists is to help clients, including the families, understand how to approach their challenges. In exposure treatment, you not only help with a few selected tough situations; you also give them the whole playbook, help them practice the plays, and help them understand how to build their own customized playbook. In essence, you give up your trade secrets. Doing so is particularly important with exposure for separation anxiety. The caregiver needs to understand not just the rationale behind exposure but the nuts and bolts of creating and implementing exposures. You ensure that the caregiver understands the critical importance of establishing a system for fear ratings, identifying fear ladder items that are practicable and fall into relatively equally spaced intervals, and the need to repeat each trial multiple times. You also prepare the caregiver for the emotional toll that exposure will bring to them. It will be more acutely felt by them because of the strength and length of their relationship with the client. Therapists need to provide their own hardwon tricks for how they endure the client’s crying and upset during exposure, while still providing loving support, always with their eyes on the prize of helping the child build their inner capacity for managing their anxiety. In the end, if you are successful, you will have completed what Wendy Silverman referred to as the transfer of control (Silverman & Kurtines, 1996) from therapist to caregiver. In many therapeutic situations, clients come to us disempowered and hoping for a magic cure. Good therapy, like exposure, can help restore the client to better functioning. Too often, the clients will attribute the success to the therapist’s actions rather than to their own. Your job is to remind them that they are ones who did the work; they are the ones who faced their fears. When you transfer the exposure leader role from yourselves to the caregivers and the child, that fact becomes more apparent. Before I turn to some of the challenges associated with the increased role played by caregivers, let me provide several examples of how



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home-based exposure experiences were designed and implemented to cement the idea that caregiver involvement is key.

Skyler Let’s start with Skyler, an 8-year-old boy with separation fears that were widespread, though they mostly occurred at home. He was fearful to be in his own room alone and was also afraid to go into his backyard. He exhibited separation concerns related to sports practice as well, though his fear of being at school had abated after his first-grade year. His fears were more pronounced when his mother was at home and his father was out of town, but he was also quite fearful when both his parents were home. Skyler had an 11-year-old sister and a family dog, Ruby. After covering multiple fear ladder items at the office such as having Skyler’s mother leave him alone with the therapist and then having both adults leave the young boy alone in the therapy room, the remainder of treatment focused on home-based exposures. In Skyler’s case, the therapist was able to conduct sessions at the home. As a result, the gradual handoff of exposure tasks could be made in the home. At first, the therapist had Skyler take him on a tour around the home and show him the “hot spots,” including the boy’s bedroom and the backyard. Being in the home allowed the therapist to assess the relative level of danger of these situations. Many times, therapists can assess the danger through interview. Direct observation, though, affords the opportunity to confirm or amend what is learned from the interview. The therapist’s assessment in Skyler’s case was that the bedroom was perfectly safe—roomy and with a view onto the backyard of the home. His room was on the second floor of the home, the same floor as his sister’s and his parents’ rooms. The backyard was spacious and seemed quite safe, with a nice playset and a large lawn area. However, the yard did front on a wooded area that was the source of some of Skyler’s fears. What if a bad guy came out of the woods?, he frequently wondered. These concerns were heightened when the sun went down. To tackle these fears, the therapist and family had created a set of fear ladder items that progressed from therapist-led, to co-led, to caregiver-led experiences. One example was Skyler spending time in his room alone. Initially, the item was practiced with the therapist starting in Skyler’s room with him, taking a rating, and then fading out of the room. In the first trials, the therapist went out into the hall. Over time, he faded down the hall, down the stairs, and then into the kitchen. Once

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Skyler had successfully completed those steps, the therapist and caregiver together co-led a similar set of trials; in these iterations, Skyler’s ratings went down relatively quickly. The focus of the co-led experiences was to provide support to the caregiver in implementing the exposure (e.g., remembering to take ratings, remembering to not engage in conversation during the trials, modeling how praise is presented). After success in these experiences, a similar set of experiences were assigned for homework when the therapist was not present. While conducting some sessions at home is preferable, that is often not possible. The next example depicts what parental engagement and involvement looks like when holding home sessions is not possible.

Sonya Sonya is a 10-year-old girl whose separation anxiety occurs in both the home and at school. Her primary concerns are that she will be unsafe when without her mother. She stays close to her mother’s side in public and stays on her own block in her neighborhood. Her mother regularly expresses concern for Sonya’s safety, including having a strong worry about her being kidnapped and believing their neighborhood to be unsafe. Sonya’s father has a different view of the situation. Having grown up in the neighborhood, he recalls his own childhood experiences of being much more independent than Sonya, including riding the bus to visit friends or go downtown. As I discuss in a later section, the difference in opinion led to couple conflict. Though unable to conduct sessions in the home, the therapist was familiar with the neighborhood and deemed it safer than the mother believed it to be. The early fear ladder items focused on situations that could be practiced at the office. A key set of items focused on Sonya being apart from an adult caregiver and then engaging in an age-appropriate activity, like throwing something into a trash bin by moving away from an adult, ordering at a food truck by herself, and walking across a large public space from one known adult to another. At first, the therapist practiced these items with Sonya alone. After a few items, though, the mother was pulled in to assist. During this experience, the therapist learned just how distressed the mother was about separation from Sonya. I discuss later how the therapist managed this challenge. The therapist used the jointly led exposure sessions to prepare the mother for the exposures she would do at home with Sonya. In working with the family, the therapist was able to identify several



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items that they agreed on as goals and that they could practice at home. One such item was for Sonya to be able to run into a convenience store in their neighborhood to buy a gallon of milk while her mother or father waited in the car. The parents agreed that the store was safe and they also agreed that they had known many 10-year-olds (and even younger children) buy things at the store. To prepare for the home exposure, Sonya, the mother, and the therapist rehearsed the situation in the office through role playing. Initially, the therapist role-played Sonya so that Sonya’s mother could practice taking a rating and providing calm encouragement with an “easy” participant. In the situation, Sonya played the role of the clerk at a convenience store. After a few iterations, Sonya switched roles with the therapist. After an excellent first practice run, the therapist whispered to Sonya for her to refuse to go in to the convenience store at first. The goal was to test both Sonya and the mother in more realistic circumstances. A fake convenience store in a therapy office is not too anxiety-provoking. The second and third trials were a bit shaky and required a fair amount of coaching by the therapist. However, they righted the ship, were able to bang out a few solid trials, and left the session feeling confident that the actual convenience store run would be a success. The plan was for them to stop on the way home from the session and then to call the therapist with an update afterward. The phone call came shortly thereafter from a beaming mother and an excited-sounding Sonya. The convenience store run had been a success! Next, let’s transition to more challenging territory in treating separation anxiety with exposure. First stop: sometimes caregivers are afraid too.

Assessing and Addressing Caregiver versus Client Fears Separation anxiety is rarely a one-way street. Often, the caregiver has as many if not more fears and concerns about separation than the child. As a result, the therapist must carefully assess the extent of the caregiver’s concerns and use those data to determine to what extent more formal and focused intervention with the caregiver is needed. Here are a few tips to consider with regard to caregiver assessment. First, in a separation anxiety case, a good rule of thumb is to plan for a meeting with the caregivers alone to understand their perspectives on the concerns of the

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client and to begin assessing their own anxiety levels about separation. It is important to proceed with care, as often times caregiver awareness of their own anxiety is low. A few quick ideas to bear in mind when assessing caregiver anxiety—I find that some therapists can be impatient with caregiver concerns that seem out of proportion to the threat posed. Recall that separation anxiety is a normative phenomenon when children are quite young—around 18 months—and that it can often reemerge in normative fashion when a child is introduced to regular time outside of the home (i.e., day care, kindergarten). The normative nature of separation anxiety is rooted in the evolution of human beings; our young are less able to defend themselves and thus their survival depends on their proximity to caregivers. As a result, it can be important to remember that separation concerns have a biological basis and involve strong, survival-oriented feelings. A second point to keep in mind is that each family comes to you having walked their own path of struggles, many of which you do not yet understand and some of which you may never understand. There are many factors that may contribute to mutual feelings of separation anxiety that may not be immediately apparent. Many caregivers had their own challenges in childhood with separation, including losses, prolonged separations, or intense anxiety around separation. Additionally, some families struggle to conceive children, undergoing stressful and painful procedures to have a child; sometimes, this heightens awareness of the preciousness and precariousness of life itself, leading to a strong desire to protect that life. Some families have lived through difficult periods of raising children involving illness or disease or even close calls with terrifying disasters, like a near-car accident or a near-kidnapping. Finally, family relationships vary across cultures, and it can be important to ensure you are being your most culturally competent self when assessing family functioning; we will return to this topic shortly. All of this is to ensure that we as therapists maintain adequate empathy when considering and assessing caregiver anxiety in these cases. It can be tempting to connect more, sometimes solely, with the struggle of the child client and neglect the fact that the caregivers too are persons who need empathy and understanding. Coming from a place of empathy can help as you move to assess and then address caregiver anxiety when intervening in separation anxiety cases. Sometimes your assessment is easily accomplished because the caregiver’s concerns are apparent immediately.



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Leila We have met Leila before, as you will recognize (see Chapter 4), as she was one of my first clients when I learned CBT. Since Leila, a precocious 9-year-old girl, had fears of “everything,” especially separation, the therapist spent the first session reassuring the caregivers that although he was a male therapist, he would not sexually assault Leila. The family wore their fears for their young daughter openly and that meant addressing their concerns was an immediate focus of treatment. In the first session, the therapist openly discussed the caregivers’ concerns, offered reassurance about his own background, and noted that all sessions would be videotaped and could be reviewed, if necessary, by the family. As the sessions progressed, the parents were involved in sessions and the therapist slowly introduced measurements of their own anxiety about planned exposure tasks. A few individual sessions with the parents introduced them to the influence of modeling on the development and maintenance of children’s fears. As they began to understand their own role in Leila’s anxiety, they began to reduce their anxious proclamations about the dangers of the world. These changes, combined with Leila’s own progress in tackling her fears in office-based exposures, led to notable improvements for the young girl. In many other cases, though, caregiver anxiety is more masked. As a result, you will need to keep a keen eye out for behavioral manifestations of caregiver anxiety. And you may even need to rely on other witnesses.

Marques For Marques, a 10-year-old boy, exposures had progressed to time away from the caregiver and around the neighborhood of the clinic (which was on the campus of a university). The first exposure trial involved Marques and the therapist walking out of the clinic and down two blocks, leaving the mother in the waiting room. The exposure was a success for Marques; his anxiety peaked at 5 but quickly decreased as they walked around the campus, noting some of the interesting places to consider for future tasks (the pizza food truck was particularly intriguing to Marques, a pizza lover). Later, the therapist learned from another therapist who happened to be walking past the waiting area that Marques’s mother stood at the window watching him walk away while weeping. That observation opened up a conversation between therapist and the mother about her own anxiety.

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As noted already, conversations with caregivers about their own anxieties are most fruitful in the context of a good and empathetic therapeutic relationship. Caregivers can be defensive when the topic turns to their own role in their child’s challenges. Some caregivers can feel blamed and will retreat as a consequence. Others will become more anxious and berate themselves for their “mistakes.” Finding the right balance can be tough. On the one hand, you seek to convey that you understand that a caregiver’s love for their child can be so strong as to drive caregivers to protect the child across (too) many situations. That is a natural human inclination and the goal is never to reduce the love the caregiver experiences or expresses. On the other hand, you want to help the caregiver understand that a child’s autonomy and independence may be undermined or stunted if the child has few opportunities to experience the world separately. It is optimally through a strong bond that a caregiver can teach a child the best lessons about autonomy. The point I often make is a developmental one. The role of the caregiver early in life is often related to ensuring survival. A good friend and the godfather of one of my children once told me about our son in the early days of parenting, “If he is alive at the end of the day, you are doing your job.” However, as children develop competencies, their need to be protected decreases by design. Therapists discuss with caregivers what steps toward autonomy make the most sense for their child, given the child’s and the family’s strengths and weaknesses. Therapists are sometimes in the role of pushing caregivers to take things a bit further than they might choose to initially. However quickly they are encouraging the move toward autonomy, they are communicating that the child will one day be an adult with their own family. They will need to learn how to operate in the world autonomously. A related point to make here is that although our roles as protectors may fade some as our children become more autonomous, that does not mean that we lose our connection to them. Underlying some caregivers’ separation concerns is a fear of losing love and connection with the child. The close connections that characterize early childhood for many caregivers is precious and many would like to prolong that time. It can be important to remind caregivers that although the form of the relationship changes as children develop, the closeness need not change. It can be useful to reflect on how that closeness happens through different developmental epochs. Granting autonomy need not mean ending closeness; instead, the closeness of the relationship develops and takes a different form throughout childhood.



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This seems like a good time to reflect on the importance of considering culture when using any treatment. Cultural views of the importance of autonomy and independence differ. In some cultures, remaining in the home and with the family is consider normative well into early adulthood. The notion of raising a child to be an independent person operating autonomously in the world comes from a largely Western and individualistic worldview. This worldview often views separation anxiety as a sign of enmeshment and overdependence in the family. It is important to bear in mind that many collectivist cultures take the view that the group good takes precedence over the individual good. As a result, there can be more “enmeshment” in families from these cultures than one might see in families from individualist cultures. Cultural competence is paramount in these situations. Avoid dictating to families what needs to happen and instead explore with them the origins of the behaviors you observe. If they are seeking treatment for separation concerns, ensure that you are assessing the family’s goals and be careful to avoid placing your own biases into the mix. The risk is adding to the goals those behaviors that you view as problematic but that are not problematic from within the family’s culture. Own your biases and focus the conversation on what the family’s goals are, sharing your own perspective on how best to address those goals. Let’s conclude this section on assessing and addressing the anxiety of a caregiver with an extended case example.

Tarik Tarik is a 14-year-old boy, the youngest of five kids and, importantly, younger than the next oldest child by 6 years. Tarik had separation anxiety accompanied by severe nightmares. Tarik’s parents adored him and it became apparent during the course of treatment that they were eager to maintain as close a relationship with him as possible. One goal for the family was to extend Tarik’s independence. One way this was operationalized was in the distance he was permitted to venture by bike away from his home. He lived in a reasonably safe area for bicycles and had a solid bike with a safe helmet. Riding alone different distances from home were added to the fear ladder as relatively high items (7 and up, depending on the distance, destination, and time of day). Of course, bike riding in the neighborhood cannot be practiced in the office. When the time came for the bike riding items, the therapist and the family invested session time planning out how the home exposures would go. The first item was for Tarik to ride with his father along

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a 1.5-mile route with which all family members were familiar; the route included the home of one of Tarik’s good friends and also passed by a local pharmacy that was a favorite spot for kids to buy snack foods. The session prior to the home exposure involved the father practicing taking a rating from Tarik before, during, and after the ride. The therapist used the clinic hallways to simulate the ride, with the father and Tarik departing and leaving the therapist and mother waiting at “home” in the office. The practice was a breeze for both and after three trials, they reported being ready to do it at home. In the next session, the success of the home exposure was celebrated and everyone was feeling quite confident and ready for the next item: Tarik going the same route solo. The session focused on practicing this using the mock route in the clinic hallways, with parents remaining at “home” in the office, taking before and after ratings. After a few successful trials, the family indicated they were ready to move on. They reported to the next session looking a bit sheepish. The therapist looked from face to face, asking, “How did it go?” Tarik’s father, Tyler, reported, “Great,” smiling broadly. Tarik was silent and looking down. The therapist noted Tarik’s mother, Sandra, shaking her head and looking embarrassed. Turning to her, the therapist asked, “What happened, Sandra?” She explained that Tarik had embarked on his journey reporting a rating of 5 out of 10; she said he seemed confident. She said about 1 minute after he left, Tyler had hopped on his own bike and pedaled off, following about half a block behind his son on the entire route. A key goal for the therapist was to tease apart and then discuss the fears of Tarik’s parents versus Tarik’s own fears. Once exposures shifted to the home, it became clear that the parent’s own fears, particularly the father’s, were a big driver for the slowing down of progress at the end. The conversation that happened next has themes that are common in separation anxiety cases. Therapist: You still had concerns about Tarik, Tyler? Tyler: Well, yes, I guess so. Therapist: What were you concerned about? Tyler: Well, he is not that great on the bike. What if he fell? Therapist: OK—safety concerns. I remember—we had covered those a bit when we made a plan earlier. Perhaps we needed to do that a bit more?



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Sandra: I don’t think it is really about safety. (Looks at Tyler.) Do you, Ty? Tyler: Maybe not. Therapist: OK—what might it be? Tyler: Well, we aren’t getting any younger, are we? And he is our youngest. Therapist: It can be tough to see them grow up. It seems like they don’t need you anymore. How did you handle that with your other children? Sandra: That was easier—we always had someone coming up behind—the baby of the bunch was always there. Tyler: Until now. Tarik is the last one. I guess we don’t quite know how to do this. I guess I don’t. Therapist: That sounds important. This is tough for you because Tarik is growing up and he is the last kid in the family. That is a challenge for a lot of families. It leads to a lot of complicated feelings. It is OK and normal to have those feelings. (Pauses.) The good news is that because it happens to a lot of families, there are a lot of ideas to use to help. And the even better news is that you already have some of those ideas because you two are veteran parents—you have seen other kids grow up and everyone, including you, did just fine. And you still stayed close to them. Let’s think a bit about how to help you feel a bit better about Tarik spreading his wings a bit. Tarik’s case involves two caregivers who largely supported each other and agreed about how best to proceed. As you may be thinking, that is not always the case. We turn next to complications that arise in treating separation anxiety when there is conflict between caregivers.

Caregiver Conflict As therapists, we see many different caregiving arrangements. In those that involve more than one caregiver, there can be disagreements about how to handle challenges that arise related to the children. Separation anxiety commonly contributes to such disagreements. In some cases, the conflict among the caregivers is restricted solely or mostly to the child’s separation anxiety. In these cases, the relationship between the

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caregivers is generally strong but becomes strained around the separation concerns. In other cases, the conflict is more widespread and is endemic of larger problems in the relationship, as hinted at in examples earlier in the chapter. These larger problems may occur in romantic couples who are parenting as well as in multigenerational parents (e.g., mother and grandmother). I discuss these two broad categories of challenges in this section and present some case examples to demonstrate how they might be managed. I begin with the simpler variety: when the conflict is largely restricted to separation concerns. A common way for this to present is when there is a temperamental match of the child with one parent and not the other related to inhibition. The case of Sonya, discussed earlier, is a good example. Her mother, Sylvia, was an anxious woman who saw danger everywhere. As Sonya was growing up, Sylvia accurately picked up on Sonya’s similar temperament. This led to a lot of protective actions that some might call overprotective. Sonya’s father, Fred, certainly did. Here is a snippet of how this conflict played out in a goal-setting session where the therapist was developing the fear ladder. Therapist: One important task we have as a team is to come up with what we call a fear ladder. A fear ladder is like a ladder that we use to climb through Sonya’s fears. Each rung is something she is afraid to do but that is not really dangerous and would be good for her to do. We start at the bottom with easier things. And as we move up the rungs, things get a little bit tougher. The top is like an ultimate goal for her to be able to do but that would be extremely difficult to imagine right now. Sonya and I already started building this the last time she and I met. I really want to hear your thoughts and ideas so that we can build the best ladder possible. Here are the ideas Sonya had (Shows piece of paper with items). We will go through these and get your ideas. And we can add things too. F red: (Looks at the list.) Oh, she can do all of those things. Sylvia: (Also looking at the list.) Maybe. Maybe not. Some of those items are really hard. F red: What is hard on here? Sylvia: Well, this one. Walking alone to a friend’s house. I don’t know about that one. F red: When I was her age, I was riding the bus by myself to get



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into the city. She can walk over to her friend Katie’s house by herself—it’s only a couple of blocks. Therapist: Sounds like you have different perceptions about that one. You don’t have to agree on how hard they would be. Let’s use a rating scale of 0–10 to show how scared she would be to do each of these. I can get separate ratings for each of you. The resulting adjustments to the fear ladder sometimes required some difficult work by the therapist as moderator, balancing the more impatient father with the more fearful mother. In the beginning, the therapist did not specifically name the conflict, instead noting that it was common for parents to perceive situations differently. After a few conjoint sessions, though, the therapist was able to find a way to be more direct. Here, they are discussing an upcoming exposure in which Sonya will walk to her friend’s house unaccompanied; the friend lives two blocks away and the walk will require Sonya to cross one moderately busy street with a traffic signal. Therapist: Sounds like Sonya has been doing great. Next up is going to Katie’s house. Solo. How are you two seeing this, using the rating scale? F red: That one will be a snap. A 2 at the worst. Sylvia: I don’t know. Crossing Frankford can be tricky. Some of those drivers aren’t paying attention. Therapist: What rating would you say, Sylvia? Sylvia: An 8. Seems like we should do something easier. I can walk her across Frankford, maybe? Therapist: We have been here before, right? If I were only meeting with Fred, it would seem like an easy one. But if only with you, Sylvia, a really difficult one. It is pretty normal for parents to not see things the same way. And you can disagree in private all you want. There are times, though, when it is important to present a united front for the kid. For Sonya. She will sense your disagreement and won’t know for sure how to act. Whether she should think it is too easy or too hard. Does that make sense? Sylvia: I guess. I still think it will be scary for her. Therapist: The first time we do things, they can seem pretty scary. When we are talking about kids, parents can sometimes feel

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scared too. With you two, there is a good balance, right? One of you is very confident that Sonya can do this and one is not too confident. So together, you make a medium confident person. Let’s think about how you can be a team and show her that medium level of confidence. Two results came from this more direct addressing of the conflict. First, the therapist was able to work with the couple about how to understand each other’s perspective better. And second, the new understanding led to the therapist being able to persuade the couple that their supporting each other and coming to a more moderate place would be best for Sonya. There are times, though, when the conflict cannot be managed quite so easily, times when the conflict around the child’s fears are just the tip of the iceberg. Adie’s case is a good example of this problem and her case also allows us to spend some time on a common separation anxiety problem: school refusal.

Adie Adie was a 13-year-old girl with separation anxiety, severe panic symptoms, and significant fear of illnesses. She and her mother had a strong and close relationship that some may have considered too close. They were both highly anxious people who preferred to be home. Adie had trouble staying in school, often refusing to leave her mother’s car to enter the school or when she did go in, often calling home to be picked up because of a stomach ache. The illness fears were complicated by the fact that she had Crohn’s disease and was often wracked with gastrointestinal discomfort. Although she was close to her mother, she had a more distant relationship with her father. He was not particularly sympathetic to his daughter’s anxiety and believed that many of her symptoms were psychosomatic. He often told her that she needed to tough things out more. He sometimes would become frustrated and, in his anger, tell her she was crazy. Needless to say, the father and mother were often at loggerheads about what to do about Adie’s anxiety. The initial treatment plan involved a set of graded exposures designed to help Adie transition back to attending school regularly. School refusal often involves plans like the one used for Adie. Working with Adie, the caregivers, and the school (in Adie’s case, the guidance



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counselor and the assistant principal), a plan was devised that allowed Adie to return to school gradually. The progression moved roughly as follows: 1. Adie arrives at school with her mother and stays in the car. 2. Adie arrives at school with her mother and reports to the counseling office. 3. Adie arrives at school with her mother and reports to her firstperiod class. She spends the rest of the day in the counseling office. Progressing to the final item . . . 12. Adie attends her first full day of school, driven by her father. Adie was strongly against the plan. Although her mother and father were initially in agreement, early exposures were implemented by the mother with the therapist’s help, meaning the therapist and mother met in the parking lot of the school each morning to prepare Adie to go in. After a few early successes, Adie dug her heels in one morning and refused to leave the house. The mother was distraught and began to believe that perhaps exposure was not the right direction for her daughter. In a subsequent session, the father and mother argued about whether exposure was the proper course, with Adie and the mother both taking the no side of that argument. The session ended with confusion and an agreement to return to the conversation at the next meeting. However, that week, Adie and her father had a blow-up in the car about her feeling sick, with both yelling at each other. Adie claimed that her father grabbed her arm roughly. The event led to the mother demanding that the father move out, which he quickly agreed to do, confirming for the therapist that their conflict was long-standing and pervasive. For the rest of therapy, the therapist worked with Adie and her mother. In the end, notable gains were made: Adie returned to school and completed her eighth grade year and she engaged in some prescribed out-of-home exposure tasks. However, sadly, as the therapist learned, there was a backslide at the start of high school and last report suggested that Adie was going in and out of a home–school arrangement. Clearly, in Adie’s case, there was caregiver conflict that exacerbated her symptoms and made conducting exposures a challenge. This was unlike Sonya’s parents who were able to find a way to work together.

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In Adie’s case things deteriorated rapidly for the couple, ending in separation and a planned divorce. Given that Adie’s more permissive parent ended up being her primary caregiver, progress with exposure was slower. The mother did not have the counterweight of the father to pull the family toward pushing Adie out of her comfort zone. However, even if they had stayed together, that counterweight was likely out of proportion to Adie’s situation. Her father’s lack of understanding of her situation was likely too severe to help bring the mother toward a more central position. As a result, Adie and her mother spun out like two satellites pulling away from the planet they orbited to create their own new system.

June June posed a different set of challenges related to caregiver conflict. A 9-year-old girl and an only child, June was afraid to be away from her mother and the two were inseparable. The father was away on business almost every week, and as a result June and her mother developed a home rhythm without him. One challenge that served as a major focus of treatment midway through concerned co-sleeping. When June began to exhibit separation fears, her mother tended to placate those concerns by spending a lot of time with her. When the father was away, the two often did “sleepovers,” sharing the parent’s bed. At first, these co-sleeping arrangements were rare and held only on special occasions; you probably already know how that can become a slippery slope. Soon, the co-sleeping occurred whenever the father was away. Just prior to starting treatment, co-sleeping became an almost every-night arrangement, triggering what you might expect would be increased conflict between the two parents. In cases like this, there are a few different strategic goals to pursue. The simplest one is the construction of a fear ladder that moves the child from the caregiver bed to the child’s own bed. In June’s case, the items on the fear ladder were developed across two family meetings, one that involved the father who was able to join in. The progression involved fading from the parental bedroom, included an interim step of a small cot placed in the caregiver bedroom, and ended with the child sleeping entirely on her own in her own bedroom. The progression also involved two separate tests, insofar as it was easier to accomplish when the father was in town, as the two caregivers presented a united front. As a result, the fear ladder included two sets of ratings: (1) when dad is home and (2)



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when dad is away. Progression through the latter ladder involved a lot of coaching and support of the mother from the therapist. A second and more difficult strategic goal in the case involved establishing agreement and alignment with the couple and June about the goal of ending the co-sleeping arrangement. Pursuit of this goal occurred across multiple sessions, including two separate meetings with the two parents alone, to come to consensus on the goal. In June’s case, the parents had reasonable insight into how their solutions to June’s anxiety had been inadvertently fueling her anxiety. They also recognized the cost to their own relationship of sharing a room and a bed with their daughter. These conversations were difficult (the parents ended up in several sessions of couple therapy). Fortunately for June, the parents were committed to each other and to helping June, and with some effor, June marched up the fear ladder. A few brief comments on co-sleeping before I change topics. In June’s case, the therapist found success in assisting the family in the transition. I chose their case because it’s a fairly typical example of cases when separation anxiety commingles with co-sleeping. The solution was not solely a matter of building a fear ladder and doing exposure. There were tough conversations here, in large part because the symptom of co-sleeping was not only about June. However, in this case, the therapist was able to work effectively with the family, and the parents in particular were able to find alignment. More challenging are those cases in which the caregiver conflict is more severe, as it was in Adie’s case. It may be that the co-sleeping is serving as much or more of a need for the adult than for the child. It may also be that the co-sleeping symbolizes the breakdown of the adult relationship. In these more severe cases, child-focused therapy may not be enough. Referrals for couple or family therapy are common and are encouraged. One other point concerns understanding co-sleeping from a cultural context. The importance of children sleeping alone is a cultural notion and not a biological one. In many cultures, co-sleeping is common and normative. Co-sleeping can also be driven by economic necessity, as some families may not be able to afford housing with separate rooms (or even separate beds). If you have a case where co-sleeping is occurring, you have the opportunity to develop your cultural competence: assess and work to understand the co-sleeping arrangement. It may well be that the family views the arrangement as a problem and counter to their preferences and goals. In such cases, the goals mentioned earlier can be pursued. However, with careful listening, you may find some instances

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in which the co-sleeping is a problem only from your cultural lens. In such cases, you will want to proceed with great care. If the arrangement is viewed positively by those involved and is creating no functional impairment, your focus can go elsewhere. In the cases I considered for this section, caregiver conflict created challenges for the therapist in implementing exposure. In such cases, therapists are often walking a line between child therapy, family therapy, and couple therapy. For the cases described so far, family conflict has arisen in part in response to a child’s often somewhat irrational anxiety about separation. In the next section, I turn to cases where the line between an irrational and rational fear becomes blurry—that is, when the child’s fear is in part an accurate perception of the situation rather than an exaggeration of it.

Child Irrational Fear versus Child Perceptiveness Perhaps the most problematic scenarios encountered in separation anxiety cases are when the child’s anxiety is more accurately perceptive than exaggerated. That is, your assessment leads you to conclude that the child accurately perceives at least some aspects of the caregiver as a reasonable basis for concern. Some caregivers do not understand the level of their child’s concern and how their own lack of understanding and empathic response exacerbates that concern. There are others who not only lack understanding but who engage in mild to severely problematic behaviors, including mental health and substance abuse problems. With these cases, you have more complicated goals. In addition to walking through typical fear ladder items, your goals will include increasing caregiver empathy, and directing caregiver behavior toward normative reassuring behaviors. With the more severe examples, you may refer the caregivers for treatment of their own. In some of these cases, too, especially with older children, you may intervene to help the child understand their caregiver’s strengths as well as their weaknesses. These cases can be thought of on a continuum. I will walk through three examples that increase in difficulty.

Will I start with the case of Will, an 11-year-old boy who worries a lot about his mother’s (Linda’s) safety. For example, when she is late coming



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home from work, he spins into intense worries, listening superstitiously to traffic reports and monitoring weather conditions. In addition, Will is an impulsive and easily triggered young man who gets into trouble at school mostly by picking fights with kids when he is mildly (or sometimes not even truly) provoked. For example, when play gets a little rough on the basketball court, Will throws punches first and ask questions later. History tells us that for a number of years Will’s father was physically abusive to Linda, too much of which Will witnessed or heard. Linda ended the relationship and moved them to a safe place. In short, there is a trauma basis for some of Will’s behaviors, including his protectiveness of his mother. It was three years later, though, when Will appeared for therapy and at the time Linda was living with her boyfriend of two years, Manuel, who was a gentle man who treated Linda with respect. Some of treatment focused on helping Will with his anger trigger. Although this is not the appropriate time to examine how this played out, it is notable that the therapist addressed this concern in part by using an exposure-like intervention, helping Will habituate to increasing levels of provocation while using anger management techniques. Exposure also focused on helping him manage his separation anxiety when Linda was late coming home from work. As these exposures were unfolding, the therapist discovered that Linda had a tendency to “space out,” as she explained it, and not check in with either Will or her boyfriend, leading to the following exchange. Therapist: OK, so sometimes you are late coming home because you space out. What are some examples? Linda: I don’t know. Like maybe Ana [from work] wanted to go shopping after work and that sounds good to me. Or sometimes I want to finish up a few more things at work. Therapist: Gotcha—that makes sense. And that gives you, Will, some other thoughts to have when you are worrying. Like, maybe she is out with her friend Ana. Will: I guess so. Therapist: I have an idea. Let’s do a quick role play. I am going to be Ana. Will, you be your mom, and Linda, you be Will. Does that make sense? Let’s get into character. (Waits a few beats until both Will and Linda stand up.) Now, Will would be at home. So Linda, you stand over there. (Gestures to the table.) And Linda and I are at work. So, Will, you come over here

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with me. (Everyone gets situated, giggling a little.) Let’s say it is 5:00—quitting time. And we start. [as Ana]: Linda? Want to go over to the Pavilion after work? Will: What should I say? Therapist: Go ahead and say yes. Remember, you are your mom. She likes to go shopping. Will: [as Linda] OK, let’s go shopping. Therapist: [as Ana] (Pantomimes driving to the mall.) Look at all of these nice dresses! (Lots of giggling from Will.) OK, time passes. It is now 6:00 p.m. (Turns to Linda.) Will expects Mom home at 5:30 or 5:40. Will, what is happening by 6:00 p.m. for you? Linda: [as Will] Oh, I am waiting here. Watching TV. Therapist: How are you feeling, Will? Linda: [as Will] Fine, I guess? Therapist: But your mom is 30 minutes late. “Real” Will—let’s coach your mom here. What might Will be thinking here at home? Will: He might be thinking his mom is in a car crash. Or that she was kidnapped. Therapist: Good examples. So, Will over here, let’s say you are thinking those things. Let’s close our eyes and imagine that for a minute. (Along with Linda, closes her eyes; waits a few beats.) What are you feeling now? Linda: Worried, maybe? More scared, I guess. If I was really worried that my mom was in a car crash, ooh. That is scary to think about. Therapist: Right. That is scary. How much would it help if you knew your mom was with Ana shopping and having a nice time? Linda: That would make it better. In this case, Linda lacks awareness of how her own behaviors are influencing her son’s anxiety. The case is relatively low on the continuum because she develops insight pretty quickly and is willing to take steps to address the situation. She started to check in with Will when she was going to be late. And she also set a more flexible home arrival time for herself, saying she would be home by 5:45 p.m. or else she would do her



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best to touch base. Success with exposure increased notably after these changes. Will was still anxious for his mother’s safety. However, he now had a lot of different thoughts to tell himself when she was late. And most times, those thoughts came right from her mouth by phone. I turn next to a more moderately challenging case: Dahlia.

Dahlia Dahlia was a bright, talkative 11-year-old who lived with her mother, Susan, and her grandmother in a small apartment. Her separation anxiety symptoms were most acute when she was at school or when Susan was out of the house. There are two notable factors in Dahlia’s case that complicated treatment considerably, both related to Susan’s health. Susan had a number of medical conditions, some of which had led to her being hospitalized for treatment. In addition, she suffered from recurring episodes of depression, sometimes so severe that she contemplated suicide. Susan’s illnesses precipitated the grandmother moving into the home to assist in caring for Dahlia. Planning exposure with Dahlia concerning her separation anxiety was challenging to say the least. After establishing a fear ladder, the therapist recognized that Dahlia’s fears were not always out of proportion to the situation. That is, her mother’s health status was at times a real concern. For example, Susan was medically hospitalized twice during their work together. As a result, Dahlia’s therapist focused her efforts on building Dahlia’s coping skills through relaxation training and cognitive work. The real creative work came when the therapist began to implement exposures. With anxiety management skills to help her, Dahlia was able to function much better at school and at home. She was a natural with relaxation skills, especially diaphragmatic breathing, and became adept at self-soothing on the sly when at school. However, in the middle of the planned set of exposure, they ran into some predictable challenges. One consistent trigger for Dahlia was when Susan did not answer the phone when Dahlia was feeling anxious and worried about her mother at school. The pattern here was that Susan’s symptoms (medical and/or depression) would begin to worsen. Dahlia’s sensitivity to them would lead her to catastrophize while at school, worrying that her mother was dying at home, had killed herself, or had been hospitalized. She would call to check on Susan and if Susan did not answer the phone, the catastrophizing would escalate. In situations like this, one could pursue a line of exposures that helped Dahlia learn to tolerate her distress about the uncertainty about her mother, resting on the

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evidence that nearly always, Susan was fine but tired and unable to answer the phone. And Dahlia’s therapist did engage in some exposures like that. However, the therapist also sought to address the concerns head-on through exposures designed to help Dahlia communicate her concerns to her mother and seek to problem-solve with her. Here is a snippet from a session. Therapist: Today, Susan, we are going to try something a little different. Dahlia has been doing a great job of coping when she is at school or when you are out of the house. She is a real pro at calming herself with her breathing and her wise thinking. She could have her own TV show, I think! Wouldn’t you agree? Susan: Yeah. Dahlia’s been doing great. Therapist: Sometimes, though, things get pretty scary for her and she wants to talk with you about that. So that is what we are going to do today. Dahlia and I practiced some before we invited you back. She can ask me for help, too, if she needs it. Before we start, Dahlia, what is your fear rating? Dahlia: A 7. Therapist: OK—pretty high. Want to take a deep breath or two before you start. (Places her hand on her belly, closes her eyes, takes slow, deep breaths.) Dahlia: (Also takes deep breaths.) Therapist: Ready? Dahlia: Yep. (Turns to her mother, looking at an index card in her hand.) Mom, sometimes when I am at school and you are home really sick, I get really scared. Susan: I know, honey. Dahlia: Sometimes I call you from the nurse’s office and you don’t answer. Then I get even more scared. Therapist: You are doing great, Dahlia. Susan: I know you get scared, Dahlia. I am sorry. The phone is so far away—sometimes I am just so tired. I . . . Dahlia: All I need is to hear your voice and know you are OK, that you are not at the hospital again.



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Susan: Oh, Dahlia. Mom is gonna be OK. Dahlia: Sometimes I’m not sure. Therapist: Dahlia, you did great at explaining that. What is your rating now? Dahlia: A 5, I guess. Therapist: Good. So, Dahlia and I came up with some ideas for how you can help her when she feels that way. You want to run through them, Dahlia, and we can see which one your mom likes best? What ensued next was a team problem-solving exercise wherein Dahlia and her mother talked over a variety of ways that her mom could let Dahlia know she was OK when her illnesses were flaring up. These included sending her to school with a note that let her know mom was OK, promising to answer the phone, moving the phone closer to her bedroom so she could access it, getting out of bed in the morning before Dahlia went to school to offer reassurance before she left, and making a commitment to follow her treatments. The case of Dahlia demonstrates how to help a child whose anxiety about her caregiver is based in some ways on reality. Dahlia’s fears sometimes went beyond the situation and the therapist helped her become clearer about when that was the case. However, her mother was sometimes hospitalized and had become suicidal once. She also had a tendency when sick or depressed to hide in her room, refuse to answer the phone, or come out to spend time with Dahlia. These instances were accurate perceptions of the actual situation—and ones where Dahlia could take some steps to communicate with her mother and request changes. Fortunately, Dahlia’s mother was open to taking those steps and things improved for Dahlia. For the last case, the situation was similar but the outcome was not as positive.

Staci Staci was a 14-year-old girl who lived with her father and his girlfriend most of the time but also had weekend visitation with her mother. Her primary problem was related to worry but she also had separation fears related to her mother. These fears included being afraid that her mother would break off contact with her or that her mother would harm herself. Staci also had other concerns related to her mother that were not

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separation-related, including feeling upset at how her mother treated her sometimes: her mother would suddenly become enraged and shout at her, saying things like “I hope I never see you again” or “You are a terrible daughter.” It is worth pointing out here that these outbursts were known by the proper authorities, had been part of the evidence considered for the custody arrangement, and were an ongoing focus of legal scrutiny. Astute clinician that you are, you may have surmised that Staci’s mother had features of borderline personality disorder; she also had a diagnosis of bipolar disorder. Unlike Dahlia’s case, though, Staci’s mother was not open to participating in therapy sessions and for the most part was not willing to have a dialogue with her daughter about her own mental health situation. Staci reported that there were many times when her visitation with her mother went well, and for a teenager she had an impressively good perspective on her relationship with her mother, thanks in part to the support of her father and his girlfriend and in part to the hard work Staci had done in therapy. The work in therapy related to separation anxiety was largely cognitive, helping Staci to see her mother in her full complexity. This is a tall order for many teenagers; Staci was a bright and thoughtful young woman with amazing perspective. In working with her therapist, she coined a phrase that she drew on when her mother got into an episode: my mom’s broken leg is acting up today. For Staci, this had a few layers of meaning. First, the problem was a real problem (bipolar, borderline personality) and it had periodic flare-ups. Second, the problem was one that her mother did not choose. She did not break her leg on purpose—it happened by accident. Last, although the flare-ups often involved scary and mean things coming out of her mother’s mouth, those words were the broken leg talking and did not represent her mother’s true feelings about her daughter. Where is the exposure in that, you may be asking? Obviously, because the mother did not agree to participate, Staci did not do exposures with her. She was able to practice some of these skills with her therapist, though. They would role-play scenarios that had happened in the past, most often with the therapist playing Staci’s role. They scripted out the scenes and built a strong set of points for Staci to use in thinking about her mother’s words or actions. Here, exposure was to the upset and fear created by her mother’s periodic actions. Staci learned to tolerate the distress these situations caused and to engage in coping activities. For example, if her mother took things too far and became unsafe, Staci had a list of strategies to use. And when she was belligerent but not



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unsafe, Staci became adept at understanding that because her mother had a broken leg, she would sometimes say and do things that were upsetting or fear-provoking. She also learned that these episodes were not her fault and that she was not responsible for taking care of her mother. As is clear, exposure with children who have separation anxiety involves a lot of complexity because of the need for a high level of involvement by the caregivers. In the next chapter, I focus on anxiety that tends to be more internal and child-focused: the anxiety that comes from children who worry too much.

CHAPTER 9

Exposure for Worry

I

turn next to a perplexing problem area when it comes to using exposure techniques: worries. Worries are common; everyone worries from time to time. The sort of worries I am talking about here are the ones that rise to the severity of a diagnosis of generalized anxiety disorder (GAD). The content of worries is highly individual. We all have our own idiosyncratic topics that can get our worry engine revving. The particular and specific nature of worries is one reason they are so difficult to treat with exposure (or with any other technique). There are nearly endless items for a fear ladder. Another reason they are a challenge is that unlike many other exposure targets, worries are almost entirely inside the client’s head. In this chapter, I consider a few procedural variations typically needed in treating kids with lots of worries.

Description GAD is a problem characterized by chronic worries and anxiety that are associated with a physiological stress response generally in a situation without an obvious stressor. In reviewing the interesting history of GAD from a nosological perspective, Crocq (2017) noted that the problem was first documented more than 300 years before the common era. At that time, it was referred to as pan(t)ophobia—a fear of everything. From this early characterization, there was a progression from neurasthenia to neurosis. In DSM-III (published in 1980), two disorders that captured the worryworts of the world were introduced: GAD and overanxious disorder (OAD). OAD was diagnosed only in children and the criteria included worries, self-consciousness, and reassurance-seeking behaviors. Despite this effort by nosologists to create developmentally appropriate 162



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criteria for children, there was a lot of overlap between GAD and OAD. Although DSM-III-R (published in 1987) retained both GAD and OAD as separate disorders, DSM-IV (published in 1994) marked the end of OAD, meaning children who worried persistently now had to be diagnosed with GAD. The move was somewhat controversial at the time, as applying the same criteria to individuals across the lifespan implied that there is relative stability in the way that symptoms for disorders present. That said, DSM-5 (published in 2013) retains GAD as the only worryrelated disorder to use when diagnosing children and adolescents. GAD is relatively common, with prevalence estimates ranging from 2 to 5% in epidemiological studies. Age trends suggest that the incidence of GAD increases with age, a finding that makes sense when you consider that worrying becomes easier to do as cognitive maturation occurs. Hearken back to the Piagetian cognitive development stages. Around adolescence comes a shift from concrete operational thinking to formal operational thinking. A teenager who can engage in hypothetico-deductive reasoning becomes an excellent problem solver; they no longer need to directly manipulate reality to imagine how different problems can be solved. However, they also become more able to imagine hypothetical future events, including upsetting ones. Ah—the double-edged sword of cognitive development! Worries are generally made-up scenarios that exist in our heads. They are not dogs, or social situations, or situations where I am separated from my parents, or upsetting physical symptoms. Worries are purely mental events. Sometimes they reference actual events, though most often they predict future events that may not even happen. As a result, you may be puzzling over how to expose someone to worries. And you would not be alone. Exposure with worries is, in my experience, some of the most challenging work we do as exposure therapists. The good news is that CBT programs that include exposure work well for children and adolescents with GAD. This chapter provides some guidance on how you can adjust the basic exposure framework laid out in Chapter 4 for kids who worry too much. There are four adjustments I will discuss: (1) inclusion of cognitive strategies, (2) worry triage, (3) the downward-arrow technique, and (4) worry exposure.

Inclusion of Cognitive Strategies Worries are thoughts. As a result, with most clients with GAD, you are going to find yourself delving more deeply into cognitive work. It’s

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useful to help the client grasp some basic cognitive techniques. I will briefly review a few of the key cognitive concepts that are important when conducting exposure with worried clients. An initial assumption is that you have established the basic psychoeducational message concerning the interrelations among thoughts, feelings, and actions (the cognitive triangle). Helping clients who worry understand that their worries are thoughts and that those thoughts influence their feelings and actions is a key to moving things forward.

Examining the Functionality of Worries With that basic premise established, an important exercise to conduct with clients who worry concerns the functionality of the worries: Often, worriers have faith that their worries are helpful. “If I don’t worry, then things will go badly”; “My worries are what have made me successful.” The faith in worry results from one of our human cognitive biases: selective attention to confirmatory information. When people have a belief (e.g., worries are helpful), they tend to focus on evidence that supports that belief and to ignore contradictory evidence. Worries are prone to this bias because they often involve the prediction of unlikely but possible bad outcomes. As a result, when bad outcomes do not come to pass, clients may erroneously believe that worrying about them was the reason they did not occur. In addition, worries can sometimes generate problem-solving efforts. If those efforts led to the thwarting of bad outcomes, the belief that worries are useful is strengthened. In addition, people forget the times when worrying did not lead to a positive outcome, thus failing to discount their utility. As I described in more detail in Chapter 5, the goal with cognitive work is not to convince the client that their thinking needs correction. Therapists are not in the thought-fixing business. Instead, they are teaching the client to become a better consumer of their own thoughts. And part of becoming a better consumer is learning to evaluate their own thoughts critically, to recognize when there is evidence for and against them, and to notice when they have habitual thoughts that are self-defeating. In addition, therapists teach how to generate thoughts to counter those habitual and self-defeating thoughts, especially through the process of weighing the evidence for and against different thoughts. To repeat: our goal is not to negate particular thoughts, but rather to help clients establish a more balanced cognitive diet. In the case of the belief in the efficacy of worries, this often means recognizing that sometimes worrying works and other times it does not.



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An example from a case may help make this clearer. Stan is an almost 17-year-old whose worries span academic, social, and family topics, including concern about whether he will be a success in life, whether others like him, and whether his mom will lose her job. Here, the therapist and Stan are talking about how worry has worked for him. Therapist: Sounds like you are saying that worry works for you? Stan: I guess. If I don’t worry, I won’t think of things that could happen. So I won’t be ready when they do. Therapist: That makes sense. Let’s look a bit closer at that idea. You know how I like to think about things like a scientist and gather evidence? Stan: OK. Therapist: So, what kind of evidence do you have that supports this idea that worrying helps? Give me an example. Stan: Hmm. Well, one time I was worried about a test in chemistry. It was a hard test and I was worried I would fail. I had heard that some kids fail that test every year. Mr. Lampinen is known for a being tough. So I worried a lot about it. Therapist: OK. And how did the test go? Stan: I did good. Got an A–. Therapist: Great job! How did the worrying help? Stan: Well, if I had not been so worried about it, I wouldn’t have studied so hard. Worrying was like the kick in the butt I needed to start studying. Therapist: Gotcha. Sounds like there were two things going on there. Worrying and then studying. Let’s break that down a little. Let’s say that this pie here (Draws a pie chart on paper) is all the reasons you got a good grade on the test. How much should I color in for the worrying? Like how big a slice? Stan: For the worrying? A pretty big slice. Therapist: OK. Bigger than this? (Draws a piece that is a quarter of the pie.) Stan: A little bigger but not quite half. Therapist: OK. (Draws.) Now how about for studying? How big is that piece? Stan: Big. Like more than half.

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Therapist: OK. Is it just those two things? Or were there other things that we should add? Stan: Like what? Therapist: I can think of a few that are good for me with tests. Maybe they are for you too? Like if I get a good night’s sleep, that helps but if not, then it hurts. Stan: Sleep. Yeah, maybe. But small. Like just a little. Therapist: OK. For me, too, if I find the topic interesting, that helps. But if boring, then it hurts. Stan: Me too. So that would be a little too. Therapist: Cool. We could probably think of other reasons. But I wanted to shift gears a little. I remember that you usually get pretty good grades. Right? Stan: I guess so. I could do better. Therapist: I seem to recall your GPA is like 3.9 or something? Stan: Yep. Not perfect. Therapist: Right. High, though. I wondered if you had ever had a test where you did not worry before taking it? Stan: Hmm. Yeah, probably. Therapist: When is an example? Stan: Well, this year my English class is pretty cool and we take these vocab tests. And I don’t worry about those. I like them. Therapist: How do you do on those? Stan: I ace them. I am good with that stuff. Therapist: OK. So if we did a pie for those tests, worry would get no piece. Stan: I guess. Therapist: OK. More evidence for us to add to our database. I am gonna stay nerdy and suggest we try another experiment. Tell me about a time when you worried before a test and it did not go too well. Stan: Well, one time I was really having a rough time worrying. For my first test in math this year, I was really stressed because Mrs. Jarvis is super strict and I thought she hated me. So I was really worried about the first test. Except I could not focus to study. I was like hyperventilating one night, it was so bad. That



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is when my mom made me come here. And that test did not go so well. A B–. I really messed up. Therapist: OK. Let’s add that evidence to our database. Here is another pie and for this math test, we see that worry gets a big slice but not in a good way. It seems like it made it harder to be successful. Stan: I guess. Therapist: Worry can be like that. Sometimes it works and sometimes it doesn’t. Let’s keep looking for times when worry works for you and for times when it doesn’t. Notice here that the therapist does not work on convincing Stan to stop worrying or that worrying is not a good idea. Instead, he acknowledges that worry works sometimes. Thank goodness our job is not to stop people from worrying. Instead, the therapist acknowledges that life after therapy will not be worry-free. Instead of seeing worry as the enemy, therapists help clients become more intentional in their use of worries. Also note that in this example, talking about a client’s worries does produce anxiety although exposure is not happening explicitly. Saying worries out loud is an important way that therapists use exposure to treat worries. I turn next to one way to make use of worries: worry triage.

Worry Triage Worry triage is a process described by Dugas and Ladouceur (2000) and one that I’ve adapted (Southam-Gerow, 2013). In their original formulation, Dugas and Ladouceur noted that there were two types of worries: ones amenable to problem solving and ones that are not. The former relate to current or ongoing situations where actions can be taken; the latter are hypothetical situations, ones that are not happening presently (and may never occur). I have amended this slightly for children and adolescents by adding a middle category: worries where problem solving may be helpful but at some later date (i.e., not immediately). A few additional sets of distinctions are worth teaching the client. First, the time sensitivity of the worry needs to be considered. Some worries pertain to pressing matters, like a test that is tomorrow. Others pertain to matters that are distant, like my hoped-for career that will

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unfold in 10 or so years. A second distinction concerns the solvability of the focus of the worry. Academic matters are often more soluble than social ones. And even less solvable are problems that the adults in a child’s life are experiencing (e.g., caregivers not getting along, caregiver losing a job) and broader societal problems (e.g., global warming, war). Helping the client learn to place worries on a solvability dimensional scale can be helpful. The final distinction concerns agency. Worries vary on the degree to which the client can influence the outcome. Some problems may be solvable but not by the client. Considering these distinctions together, the therapist and the client can walk through the client’s worries and place them in different categories, based on dimensions such as (1) timing (e.g., now, in a few hours or days, in a long time, never), (2) solvability (e.g., easily solved, solved with some difficulty, solved with extreme difficulty, unsolvable) and (3) agency (e.g., I can solve it alone, I can solve it with help, I cannot solve but others can).1 The process of worry triage involves placing worries into different categories. The first competency to develop, then, is making those categorizations. What happens after worries have been placed in their categories? Some examples will demonstrate. Figure 9.1 is the worry list for Candice, a 13-year-old with worries that ranged from health concerns to academics to friendships. She is one of those kids who, if you are her friend, worries about your health too, and is always quick to offer hand sanitizer or to suggest orange juice or echinacea. For her list, the therapist created codes to help place the worries into triage categories. They used a color coding system for three different categories: (1) timing: now (green), later (yellow), maybe never (red); (2) Is there a solution?: yes (green), maybe (yellow), probably not (red); and (3) Can I do the solution?: yes and by myself (green), yes but with others (yellow), and probably not (red). For those worries that were all green, the therapist and Candice used a problem-solving approach to identify ways to deal with the concern. For example, for the algebra test, Candice identified ways to study as well as ways to manage her anxiety about the test (e.g., relaxation strategies). There are excellent resources available that describe problem-solving interventions in detail (e.g., Chorpita, 2007; Kendall, 2018; Manassis, 2012), and I recommend using these for any worries that are sorted into the green pile. For those worries with yellow or red, Candice and her therapist used 1In

my earlier book (Southam-Gerow, 2013), I present a game called “Worry Sort” that involves sorting worries into categories like this.



Exposure for Worry  169 SCHOOL STUFF I will fail my algebra test GREEN - GREEN - GREEN I won’t get into the honors high school classes YELLOW - GREEN - GREEN My art teacher does not like my work YELLOW - YELLOW - YELLOW HEALTH STUFF I am going to get a cold GREEN - YELLOW - YELLOW I am going to get diabetes RED - YELLOW - GREEN I might have cancer RED - YELLOW - YELLOW SOCIAL STUFF Julia is mad at me again GREEN - YELLOW - YELLOW Aron is going to fail his English paper GREEN - YELLOW - RED My mom and dad are disappointed in my grades GREEN - YELLOW - YELLOW

FIGURE 9.1.  Candice’s worry list.

a variety of cognitive strategies to help her accept aspects of the situation or to engage in activities to take her mind away from distant and unsolvable worries, especially those over which she has limited agency. For her concerns about getting a cold, they used a combination of problemsolving strategies to identify ways to remain healthy (e.g., eat well, sleep well, wash hands appropriately) combined with acceptance- and databased cognitive approaches, such as noting that the average person has two to three colds per year, that colds are uncomfortable but not fatal, and that colds can actually help you build a stronger immune system. For those most challenging worries (those including red), a variety of approaches were used. One is described later in this chapter, worry exposure. For Candice, the therapist also used a lot of cognitive strategies to help her develop a strong roster of counterthoughts for her automatic thoughts that each little bodily symptom meant she had cancer. As well, the therapist developed affirmations about her health (“I am healthy most of the time”; “I am good to my body”). Finally, he helped Candice develop a set of activities that helped her remain active, such as involvement in an after-school group and the development of an exercise regime. These activities contributed to her health and kept her busy, with less time to fret about her health. Teaching a client how to triage worries is often critical for clients with GAD. The technique also celebrates and enhances the adaptive qualities of worry while undermining its less adaptive qualities. Next, I discuss the downward-arrow technique, a staple of exposure with clients who worry.

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The Downward -Arrow Technique In the late 1990s, a so-called third wave of CBT emerged, one that integrated a variety of novel cognitive and behavioral concepts into more traditional CBT approaches. One example of this was referred to as “experiential avoidance.” The term came to characterize individuals who became anxious as their awareness of their internal, usually emotional, experiences increased. As a result, these individuals engaged in behaviors designed to avoid those internal experiences. Worry was one notable way to engage in experiential avoidance. Because people can worry about any and every thing, they can focus their worry away from the feelings and thoughts that trouble them most and toward more trivial concerns. The more troubling feelings and thoughts are kept hidden. And the cognitive activity keeps awareness of emotions at a distance as well. Although the technique of the downward arrow originated before the popularization of the concept of experiential avoidance, the new concept gave the old technique new life. Basically, to follow the downward arrow, you engage the client in a cognitive exercise that starts with an initial, worried thought and follow that thought to what the client believes is the logical conclusion. Let me share a nonclinical example from work I have done teaching stress management approaches in schools. Here is what it can look like to do the downward-arrow technique in a group classroom setting: I nstructor: Now I think you get how thoughts, feelings, and actions all work to change one another. Let’s dive more deeply into our thoughts. Let’s focus on worries. Thoughts we have that are guesses about what is happening or what will happen that make us feel anxious. Who can think of something like that—a worry? Student 1: I am really worried today that I will fail my Spanish quiz tomorrow. I nstructor: Great one to start with. OK, team, let’s play a game we call “Then What Happens”—we just take a worry and we keep asking the question “And then what?” So, our starting worry is “I will fail my Spanish quiz.” And then what will happen? Anyone? Student 2: I will probably fail Spanish this year. I nstructor: I will probably fail Spanish this year. And then what?



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Student 3: My parents will be really mad. I nstructor: OK—parents will be mad. And then what? Student 2: I might get kicked out of school. I nstructor: So, now we might get kicked out of school. Student 1: Oh no, I will never get into UVA. I nstructor: Now we won’t get into UVA. And then what? Student 4: I won’t get a good job. I nstructor: Now we don’t have a good job. Student 5: I am gonna be poor. I nstructor: You guys are good at this game. So now we are poor. And then what? Bear in mind that this example is in a group format; as a result, the escalation often comes quickly, as the young students lean into catastrophizing. In school-based work, I commonly end up with the student who fails their Spanish quiz living under a freeway overpass, disowned by their family, missing the family and the family cat. In individual sessions, I use the same downward-arrow approach and uncover many of the same terrible expected outcomes. The point of the downward arrow is twofold. First, I aim to uncover the deeper fears that lie under the surface of the initial worry. The concern about the Spanish quiz is based in a fear of failure linked to fear of a lifetime riddled with failure and perhaps being disowned by those the children love the most. They fear that at their core, they are failures and that once that failure is laid bare, the world will reject them. Awareness of the longer-term fears provides good fodder for the sort of cognitive work I describe earlier in this chapter and also in Chapter 5. Often, the alternative thoughts are easy to come by once I have taken the arrow so far down. Although a poor grade on a quiz in grade 6 is indeed a disappointment, the evidence that it leads directly and ineluctably to a life of poverty is sparse indeed. And remember, too, that the thought that started it all was about a future quiz—the actual grade is not yet known! The second reason to use the downward-arrow approach is related to case conceptualization and a major goal of cognitive therapy—the effort often helps to identify the core belief(s) of your client. Let’s consider briefly the fear of failure raised here by the possible poor grade on the quiz. A fear of failure may be rooted in a few different core beliefs. One could concern the social ramifications of the failure: others (family, friends) will be disappointed, will love the client less, and will eventually

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abandon them due to the failure. The fear of abandonment may rest at the core of the fear of failure that spurs worries about poor grades on quizzes and the like. Alternatively, the fear of failure may derive from a fear that the client lacks the skills to be a success—that they are incapable of doing well in this life due to flaws in who they are. The concern here is that they are lacking in some fundamental ways and defective in their very nature. A third core belief could be that the client must be perfect and any blemish on their perfect record leads to cataclysmic doubts. The core belief of perfectionism leads them to consider that every mistake, even the smallest ones, are evidence of their carelessness and unworthiness. There are other core beliefs that could lead to these worries. And other worries may take you to other core beliefs (e.g., I am unlovable, I am too fragile to handle stress). The second goal of the downward arrow is to expose, gently, the core belief(s) of the client, as these help you to understand their suffering better. Also, for many clients, the core belief(s) become key clinical foci using cognitive techniques. For more on cognitive approaches, see Chapter 5. Last, I turn to the final adaptation of the exposure technique for worries: worry exposure.

Worry Exposure Worries falling into the red and yellow categories in the worry triage can be among the most perplexing for clinicians looking to do exposure. Helping expert worriers manage their worries can feel a bit like the carnival game Whack-a-Mole; once we strike one mole down with a mallet, another pops up. There was once an assumption that behavioral approaches would not work for fears and anxieties because exposure did not address what was considered the root of the problem. Contemporary perspectives view the roots as being varied in nature and cause. That is, there is agreement that treatment must go below the surface but less agreement about what lies therein. The downward arrow is one way to assess the root cause of a client’s worries. Worry exposure is another. In our clinic at, we draw on Van der Heiden and Ten Broeke’s (2009) excellent primer on worry exposure. The article is an excellent resource and I strongly recommend it. Worry exposure most closely resembles imaginal exposure. With typical imaginal exposure, the client may imagine themselves in the presence of a feared stimulus like a spider or else may imagine themselves engaging in a feared situation, like a speech. The goal of imaginal



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exposure is for the client to create a vivid picture of the feared stimulus, observe their anxious feelings, allow the feelings to occur, and to remain engaged in the exposure until habituation has occurred.

Identify the Focus with the Downward-Arrow Technique Remember that with worry exposure, the client is focused on worries that are in the red or yellow categories: situations that are hypothetical and not easily (or at all) amenable to direct actions on the part of the client. As a result, the exposure focus will be some hypothetical outcome—that is, something that has not (and may never) occur. Thus, to conduct worry exposure, the first tasks are to identify a common worry and then to engage in the downward-arrow technique—to see where that worry leads. One need not engage in the entire downward-arrow process. Instead, one can cut to the chase and ask: What is the worst possible outcome you imagine that could come from that worry? Once you arrive at the worst possible imagined outcome, you have found your exposure focus.

Ask for Full Sensory Details Next, ask the client to conjure a vivid image of the worst possible outcome. Doing so often requires some exploration of the situation to generate an evocative description. I often find it useful to ask clients to pretend like they have to mock up the situation like a scene in a play that will be watched live. You can ask for details to create a full sensory experience. Some may recognize that this is parallel to how exposure works in a trauma narrative. In the end, help the client generate a description of the worst possible outcome that is sufficient to help them bring that situation to life inside their mind.

Take Ratings That is what happens next: the client engages in imaginal exposure wherein the worst possible outcome is held in the mind as vividly as possible. As usual, the exercise begins with an anxiety rating. Ratings can be taken during the process too, though fewer is better, as the rating process can distract from the imagined scene. As one example, let’s return to the client Candice, whose worries centered in part on developing an illness. One worry she had was related to her frequent headaches. She worried this could mean she had brain cancer. Here was her worst-case scenario:

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“I am in a hospital bed wearing a gown. My head is bald because I have a brain cancer called astrocytoma. I have been having radiation and chemotherapies for a long time. I am tired and feel awful. The monitors in the room are beeping and there is a doctor standing at the edge of the bed, reading from a tablet. My parents are in the room with me, looking concerned; I can see tears in their eyes. We have just learned that the treatments are not working and that I am going to die.” The initial goal in worry exposure is to hold the scene or image in mind and engage in it truly and fully, much as one would in an actual in vivo exposure. However, after some time engaging in the imaginal exposure, the procedure for worry exposure becomes quite different from what we have come to expect from exposure.

Help Generate Alternative Scenarios Rather than focusing solely on the feared stimulus, the therapist also engages the client in an exercise to generate alternative scenarios and explanations that start from the initial seed of worry. The goal changes to identifying other hypothetical futures. The alternatives are generated in a brainstorming session, with client or therapist writing them down for later use. Consistent with the overall goal of cognitive approaches as we have discussed them in this book (see Chapter 5), we are not trying to convince the client that they won’t develop cancer. Instead, we are helping them to see that although cancer may be one possible future, there are many others. Further, the alternative list can be evaluated with regard to how probable the outcome is given the seed of the worry. For example, if the seed is the failure of a Spanish quiz, then we consider how probable is it that the client will end up a homeless person living under an overpass versus having to repeat a grade versus having to repeat Spanish 1 versus having to study harder, and so on. Finally, the generation of the alternative list is an opportunity for the therapist to prompt the client to see how their possible future actions may forestall or even prevent a hypothetical future disaster. You can ask a variety of questions to clients to consider opportunities early in the chain of disaster that would have reduced the chance of it occurring altogether. For instance, if a middle schooler failed the Spanish quiz, it may help if they recognized that their caregivers and teachers may reach out to provide support and guidance. Further, one may learn that others



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in one’s life have failed quizzes before and still managed to avoid a home under a freeway overpass. For Candice, her alternative list looked like this: • People get headaches for lots of reasons: being hungry or tired, having a cold, being stressed about something, having allergies. • Cancer symptoms are usually pretty severe and usually involve more than headaches. • I have seen my doctor every year and she does not think I have cancer. • I am a pretty health-conscious person and do lots of healthy things (eating, exercise). • Even if I had cancer, my family and friends would do everything they could to help me. • Thinking I might have cancer is not the same thing as having cancer—and thinking I have cancer cannot give me cancer. The last alternative was one that Candice found really valuable. A philosophical girl, she really latched onto the idea that scientists call thought–action fusion. Her own burgeoning cognitive development helped her to understand that her excellent imagination, so much fun as a young child, also led to her having thoughts that ranged quite far from actual situations. Worry exposure can be difficult for the client (and the therapist). Who really wants to think about these worst-case scenarios? But as with all of the exposure foci I have covered in this book, the aim is to overcome the nearly ineluctable pull of avoidance. Because little worries often mask larger and more global concerns, focusing on those serves to clarify the core concerns for the client. As I hope has been made clear here, worry is a tough focus for exposure. Further, it is the one focus area in the book where there is little doubt in my mind that cognitive work will be a big part of the treatment plan. All of that said, the evidence is compelling that CBT programs that contain exposure are quite effective for children and adolescents diagnosed with GAD. That cognitive reframe may help you when you find yourself with your own worries about how well treatment will work with that worrying client sitting in your waiting room.

C H A P TE R 10

Exposure for Panic Disorder

T

he last problem area is panic disorder. I begin with a brief description of the problem, as well as common presentations. Then I describe variants of the basic exposure procedures outlined in Chapter 4 relevant for panic. Clinical examples are used liberally throughout.

Description An important initial distinction is between panic attacks and panic disorder. The former are more common than the latter. A panic attack involves at least four physiological or cognitive symptoms that occur in the context of a sudden surge of intense, sympathetic-nervous systemdriven fear that reaches a peak quickly. These attacks can occur for any number of reasons or no reason at all. As a result, panic attacks can occur in the context of many other diagnoses, as well as in the absence of a diagnosis. Many who experience a panic attack mistake it for a heart attack; indeed, emergency department visits are common for those experiencing a panic attack. Panic disorder involves repeated panic attacks, at least some of which are unexpected. Although panic disorder has a typical onset in the 20s, many cases present in adolescence and specific treatment programs have been developed and tested for panic disorder for teenagers (e.g., Pincus, Ehrenreich, & Mattis, 2008). Exposure interventions with panic disorder are well developed, especially with adults. In fact, panic control treatment developed by David Barlow and Michelle Craske (1994) was one of the first treatments tested in a community setting in the 1990s, when the push to 176



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test treatments outside of university labs was just beginning. There are some distinct and important differences to consider with the basic procedure outlined in Chapter 4 and I will cover those in some detail here. Exposure with panic disorder can be summarized as a three-step process: (1) interoceptive assessment, (2) interoceptive exposure, and (3) in vivo exposure. I will cover each of these, but I begin with a cautionary statement, some definitions, and some key information about psychoeducation.

A Cautionary Statement Interoceptive exposure is a potent and well-tested treatment approach. It works well for many clients. However, you will want to be sure that the client does not have any medical reasons not to engage in the exercises described here. For clients with cardiac or respiratory conditions, some or all of these exercises may be contraindicated. If you, the client, or their family have any concerns, obtain authorization to speak with the client’s physician and consult with them.

Some Definitions I need to be clear what I mean by the term interoceptive. The dictionary definition is “of, relating to, or being stimuli arising within the body and especially in the viscera”—that is, internal, physiological experiences. The notion driving exposure treatment for panic attacks and panic disorder is that the client is having trouble managing their feelings about these internal physiological experiences, and thus, these experiences must be the focus of exposure. As will become clear, the approach of exposing a client to their internal experiences has some advantages: most therapists are able to conduct exposure exercises that require only the presence of the client!

Psychoeducation An important and initial psychoeducational point to make is that people can learn to fear internal bodily feelings because of their association with panic attacks such that those internal cues can lead to panic attacks. To make this clearer, let’s take a useful detour into an imaginal situation. Put yourself in a client’s shoes. Your name is Sara and you are 16.

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You have had a few panic attacks in the past few weeks and now you are quite frightened of having another one. The attacks are terrifying and they last for what seems like a long time. As a result, you have become vigilant in tracking your internal state so that you can be prepared if another attack is coming. Because a few came out of the blue, your vigilance is intense; you are constantly scanning your heart rate, respiration, and your digestive system waiting for some sign. You want to be able to predict what is causing those terrible attacks. One day, your heart rate goes up a touch. Just a touch. And for no reason. Since you are monitoring yourself so carefully, though, you notice it. Most people would not even notice. Because your eyes are glued to the monitor, though, you see the small spike. And when you do: oh my! You feel anxious. You think, “Oh no, here comes another one.” That thought floats around in your mind for a moment and leads to another small heart rate increase. You notice that one too. And so you start to breathe a bit more shallowly, almost gasping for a breath. You think: “Not again! I can’t handle another one.” That thought and the shallow breathing leads to another uptick in your heart rate. Now it feels like your heart is pounding out of your chest. Here comes a panic attack. An important point to note is that all day, every day, our hearts (and many of our internal processes) are doing their thing, changing a little up and a little down, sometimes for no reason that we could find if we looked carefully. And this is normal, an amazing mystery of our human physiology. There is even some data to suggest that high resting heart rate variability (changes in time between heart beats) is a positive health indicator. For some, though, those little and sometimes random fluctuations in our bodily functions are an indicator not of a normal body doing work but of the first signs of a panic attack. Sara’s example depicts the unfortunate cycle that happens for many who suffer panic attacks, a cycle that can produce a panic attack out of thin air and a little random blip in the old heart rate. This cycle becomes the core of the psychoeducational point you make to clients with panic attacks and panic disorder. You can help them break the cycle. However, to do so, they are going to have to go through the cycle. They are going to have to get more comfortable with the cycle itself, especially its unpleasant parts. They expose themselves to the cycle so that they get used to it; the cycle becomes more predictable, like the sound of a train in the distance or the rumble of the air conditioner when it kicks on, rather than the startling sound of an unwelcome and unpredictable intruder coming to do harm.



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Interoceptive Assessment The first step in exposure for panic disorder and panic attacks is usually interoceptive assessment. Interoceptive exposure is a procedure that involves exposure to each physiological symptom that is relevant to the client’s panic symptoms. To identify which ones to use in exposure, there is a pretest that involves brief practice of a wide variety of physiological exposures. In the interoceptive assessment phase of treatment, the main goal is to ensure that the client practices a wide range of possible panic symptoms so that you can identify the best set to use in subsequent sessions. Table 10.1 summarizes the most common experiences to practice. There are a few alternative interoceptive exposure experiences to consider for specific panic symptoms not captured by this standard set. 1. For chest pain: Tell the client to take a very deep breath and then hyperventilate. 2. For heat and sweat: Have the client sit in a very hot room (space heaters can be helpful). 3. For throat tightness: Tie a tight scarf, necktie, collar, etc., around the client’s neck. 4. For choking: Place a tongue depressor or toothbrush on the back part of the client’s tongue or have the client place a finger toward the back of the client’s mouth. During this assessment phase, the therapist and client choose the experiences together and their order of practice. In many instances, the therapist will either demonstrate or conduct the exercise along with the client, and so it is strongly recommended that you practice these in TABLE 10.1.  Interoceptive Assessment List 1.  Shake head: Shake head side to side (30 seconds). 2.  Quick up: Put head between legs (30 seconds) and then lift quickly. 3.  Run: Run in place or go up and down a step (1 minute). 4.  Hold breath: Hold breath as long as possible. 5.  Tense: Hold total body tension or hold push-up position (1 minute). 6.  Spin: Spin in a swivel chair (1 minute). 7.  Hyperventilate: Hyperventilate (1 minute). 8.  Straw: Breathe through a straw or as slowly as possible (2 minutes). 9.  Stare: Stare at a spot on a wall or at reflection in a mirror (90 seconds).

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advance of the session. When you are demonstrating the exercise to the client is not the time to learn how distressed you become during straw breathing. Each exercise lasts 30–90 seconds, so the entire list can be completed easily within the time frame of most therapy sessions. Before each exercise, you will record a rating of how much anxiety the client anticipates. After the exercise, there are three separate ratings to consider collecting, along with asking the client to describe the sensations they experienced. The three ratings are (1) how much anxiety the client experienced during the exercise, (2) how intense the physiological feelings were during the exercise, and (3) how similar the feelings and anxiety were to those experienced during the client’s panic attacks. The basic script for these exercises is as follows: “We are going practice a range of activities that tend to produce bodily reactions similar to the symptoms of panic attacks. As we talked about, these are natural and normal things our bodies do all the time and they are not dangerous. You will engage in each exercise for a specified period of time ranging from 30 seconds to 2 minutes. Please try your best to engage in the exercise for the whole time. However, if you feel you must stop, you can. After each exercise, we will discuss the sensations you experienced along with your ratings of (1) anxiety, (2) the intensity of the sensations, and (3) the similarity of the sensations to your panic attacks.” The exercises themselves follow a pattern. First, you demonstrate the exercise. This is important so that the client can understand what is expected. Further, your demonstrating the exercise provides evidence that the exercise itself is not dangerous. Given that you will at a minimum be demonstrating each exercise, you can understand my advice to practice these in advance of the meeting. Some therapists have videotaped themselves or someone else completing the exercises as a demonstration. Doing so permits you to talk while watching the demonstration to highlight aspects of the exercise. After the demonstration, let the client know the duration of the exercise and take their initial anxiety rating. The client is then encouraged to engage in the exercise for the specified duration. After the exercise, query the client’s sensations. What did they feel? Often, the exercises create symptoms throughout the body and not solely in the targeted area. After recording the sensations, the three ratings are collected. Prior to starting the next assessment exercise, allow the client to return to a reasonable baseline, like a cleansing of the palate when tasting food.



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The following case presents a relatively straightforward example of how interoceptive assessment operates. The client, Nile, was a 17-yearold high school senior whose panic attacks were occurring in school and had led him to refuse to go to school. Therapist: So, here we go. First one on the list—and hopefully the easiest—is tensing. It can be easiest to do this like a push-up or a plank. Like this (Planks). Just hold this position for about a minute. (Waits a minute in plank position and then stands). Let’s do an anxiety rating for that one before you get started. Nile: No problem. Like a 2. Therapist: A 2. OK. Ready and go. Nile: OK. (After a moment of hesitation, assumes a plank position). Therapist: (watching a timer on her phone) And stop. Great job with the plank—you held the position really well. What did you feel in your body? Nile: It was kinda hard. Was that a minute? Seemed like a long time. Therapist: I know—time is funny like that. What feelings did you notice in your body? Nile: Oh, right. Um, not much. Like my arms got tired. Therapist: OK, so your arms were tired. Got it. What else? Any tension anywhere? Nile: Yeah, I guess. Like in my arms. Oh—and in my chest too. Therapist: Right. Tense arms and chest. What else? Nile: Nothing. Well, at the end, I started to wonder if I could stay pushed up you know. Therapist: Ah—so you had a thought? Like “Hmm, I wonder if I will be able to hold this”? Nile: Yep. Therapist: What happened when you had that thought? Nile: I sorta thought, “You can hold this. You can do a lot of pushups.” Therapist: Good observation, Nile. Sometimes our thoughts can increase our anxiety and sometimes they can help. Let’s do those ratings I mentioned now. How anxious were you during the exercise about the sensations?

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Nile: Not at all. No big deal. Therapist: So what rating from 1 to 10, with 1 being lowest anxiety and 10 being highest? And the rating is about the sensations, like how you felt about them. Nile: Like a 1. Easy. They did not bother me. Therapist: OK—a 1. Next, how intense were the feelings of tension? Just the feelings themselves, like how tense did you feel in your body from 1, meaning none, to 10, meaning incredibly high? Nile: The tension like in my arms? That was medium, like 6. Therapist: A 6—OK. Last one: How similar were your anxious feelings and the intenseness of the tension to the way things are during your panic attacks? Here a 1 means not at all like my panic attacks and 5 means sort of like my panic attacks and 10 means exactly like my panic attacks. Nile: Oh. Well, I guess I do get a little tense when I am having a panic thing. But I hardly notice that, so maybe like a 3. Therapist: A 3. OK—great—thanks. Next up is spinning. We are going to need a swivel chair for this one. I will now offer a few final comments about the interoceptive assessment process. As noted, it is often possible to complete all of the exercises in a single meeting. However, in case you cannot do so, you can complete the remaining exercises in the next meeting. When you do so, you may find it useful to repeat one or two of the easier exercises at the outset, so that the exercises get off to a smooth start. It can be challenging for a client to jump right into the deeper end of the pool; work your way back in.

Countering Avoidance Another relatively common occurrence, especially with older clients, is some avoidance before and during the assessment process. Although the exercises generally range in the anxiety they produce in the client, it is important to remember that the sensations themselves are the feared stimulus for clients with panic disorder. As a result, even a minute of exposure in a safe and controlled environment can produce a lot of fear. Accordingly, some clients will miss sessions when interoceptive assessment is planned. In addition, they may engage in distraction efforts as the therapist lays out the exercises. This may look like the client suddenly talking more than usual about their school day or the client may take a



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strong interest in learning more about the therapist (“Did you see [the latest hot movie or TV show]?”). A good approach with avoidance behaviors is Name, Normalize, Empathize, and Encourage (N2E 2). First, you name the problem. You point out that the client may be avoiding the upcoming interoceptive assessment. “Remember that avoiding what we are afraid of is part of having trouble with anxiety. Avoidance does the trick at the moment, but in the long run, it only makes the anxiety worse.” Next, you normalize. “Many people feel like avoiding when facing situations that make them uncomfortable.” This leads us right to empathy: “I understand 100% how that feels. I have been there for sure. When I am afraid to try something, I feel a strong pull to avoid.” Last, you move to encourage. “I know it will be tough. Remember that we’ll be moving forward at a pace we negotiate together. And I will be there with you every step of the way. I know you can do this.” Another challenge that occurs sometimes is that a client will suggest that one of the exercises is not relevant to them. For example, the client might say, “That staring one won’t bother me. I look at myself all the time in the mirror.” Other times, a client will claim, “Oh, just so you know, if we do the spinning one, I will throw up.” In these instances, you will need to balance awareness of possible avoidance with credible attempts by the client to save time (or your carpet). If an exercise is deemed too easy or not relevant by the client, you have a few choices. First, you can point out that it is useful to start with an easy one. If the exercise is easy, it can be dispatched in a few minutes. Alternatively, and especially if pressed for time, you can postpone the exercise in favor of those that the client deems more relevant. If you come to suspect that the client was not being 100% honest about how tough it would be, you can always return to the exercise. If the client expects the exercise to lead to vomiting or some other

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unpleasant outcome, you also have a few choices. First, remember that each exercise is designed to create a set of physiological sensations that the client may fear. In the case of the spinning chair, the feeling there is dizziness. One can create dizziness in a few different ways that may be experienced more gently, such as by drawing a circle in the air with one’s nose or walking in a small circle in the room. Of course, some clients will even balk at these exercises. Again, your judgment is needed to determine if the effort to avoid is more related to the uneasiness about vomiting or the fear of the symptoms. If the latter is the case, it is important to find some way to practice the symptoms—they are part of the set of feared stimuli. If the concern is really mostly or totally about not wanting to vomit and that vomiting is not feared as much as it is disliked, then you can choose different exercises. At the end of the day, the outcome of the case is not likely to hinge on the success of that single exercise. Finally, there are times during the assessment when the client wants to stop an exercise. If the client asks to stop any exercise, allow them to stop. You can engage in coping at that point, including relaxation techniques and even some cognitive coping. Chapter 5 covers a few common anxiety coping strategies. Once the client has become calmer, the goal is to reapproach the exercise. You may find it useful to run through the N2E 2 cycle referenced earlier. You may also find it useful to reflect with the client on the psychoeducation material, reminding them that the exercises will be tough at first, giving way eventually to things getting easier and easier. The first few are always the toughest. However, sometimes even after all of this effort, the client will remain stuck. Here, more motivational approaches are needed. Your familiarity with motivational enhancement approaches (e.g., Naar-King & Suarez, 2011) can be quite helpful. One final point to make about interoceptive assessment (and that applies to the interoceptive exposure process) concerns confusion clients may express about the difference between the breathing-related interoceptive experiences and breathing exercises that are often included in CBT programs for anxiety. Breathing exercises as a coping method are used to help clients when their breathing has become irregular or when they are experiencing diffuse stress or worry not yet rising to a panic attack. The goal is to return the breathing pace to a regular rhythm and to create a state of relaxation. Interoceptive experiences are breathingrelated exposures designed such that the client experiences feared sensations maximally, with the notion that repeated exposure will help the client develop new learning about the sensations related to breathing



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shallowly or quickly, for example. As a result, during interoceptive experiences, efforts to use breathing exercises designed to calm the client are contraindicated.

Interoceptive Exposure Once the assessment process is completed, you are ready to move on to exposures. Bear in mind, though, that the assessment process was in fact already the start of exposure. As you move to the official exposure phase, though, the goal changes from understanding how the client experiences each of the exercises to the client developing mastery over them.

Review the Rationale When you transition to the exposure phase, it can be useful to review the rationale for interoceptive exposure. In brief: 1. The exercises are intended to induce repeatedly the physical sensations similar to those the client experiences in naturally occurring anxiety/panic episodes. 2. Doing so repeatedly and in a controlled setting will lead to a decrease in the client’s automatic fear reaction to the sensations. 3. Over time and repeated exercises, there will be a decrease in the likelihood of panic attacks and anxiety when physical sensations occur naturally (as they are wont to do). With the client reoriented to the rationale, it is time to line ’em up and knock ’em down. Hopefully, the assessment provided a clear pathway to use.

Determine the Fear Ladder Sequence In collaboration with the client, review the Interoceptive Exposure Worksheet (Form 10.1, at the end of the chapter) and determine the order for conducting exercises, ordering from least to most distressing. In most situations, it is only worthwhile to focus on those exercises that received anxiety and similarity ratings of 3 or more out of 10. In some instances, it is worth starting with exercises that received lower scores, (client reports tremendous fear of the exercises, client seems to

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underreport distress). As with all exposure, the goal is to start with and build from success. Thus, start with exercises that seem like they will go well and still produce a sense of accomplishment for the client. A good rule of thumb for interoceptive exposure can be to aim for conducting two or three sets of exercises in a session. The primary goal is to reach habituation with each exercise. Early on, you may be able to do this with more than one exercise. As you approach the more difficult and anxiety-provoking exercises, however, you may find that you can only achieve habituation for one exercise. And it may sometimes take more than one meeting to achieve habituation for some of the toughest exercises. Furthermore, each subsequent meeting should involve at least one repeat exercise from the previous meeting to test for sustainment of the habituation. As a result, if the goal is to proceed through five exercises, you may need seven to eight sessions to get there. The basic structure of the exposure will be familiar. You start with preparation: (1) establish a signal for when the client is experiencing distressing sensations from the exercise (e.g., raising a hand) and (2) remind the client to focus on the physical sensations during the exercise—no distraction or anxiety management allowed.

Conduct the Exposures Next up is the actual exposure exercise. Ask the client to begin. Unlike the assessment portion, the therapist does not usually participate in the exposure, as they need to be more attuned with and focused on the client. As the client engages in the exercise, observe for signs of distress as well as the distress signal. Avoid speaking as much as possible and avoid direct eye contact so as to avoid any nonverbal communication. Once the client reports the distress signal, remind the client that the exercise will continue for about 30 more seconds (more like 10–15 for breath holding).

Debrief Next is the debrief. Ask the client to rate intensity, anxiety, and similarity of the sensations using the worksheet. If the client is still experiencing high levels of distress, you can guide them in using anxiety management strategies such as relaxation or cognitive strategies (see Chapter 5 for some examples) until their anxiety has decreased and the physical sensations have abated. Next, process the exercise with client. Ask the client if they noticed any new thoughts or feelings about the experience. If their



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initial beliefs about the symptoms produced by the exercise are shifting, encourage them to notice that shift.

Repeat the Exposure As with all exposure, next you hit the repeat button. The goal here is to reach an anxiety rating of 2 or lower on a scale of 10. Note that the goal is related to the anxiety rating. It is 100% acceptable for the intensity and similarity ratings to be high. The goal is for the anxiety rating to decrease even with high intensity and similarity ratings. Aim for the anxiety scale being 2 or lower on at least two successive trials. It can often be useful, given how quickly the trials go, to repeat with a rating of 2 or lower for 4 or 5 more trials to solidify habituation both physiologically and cognitively. Once you have reached habituation, praise the client profusely and then assess whether there is adequate time and client motivation to move on to the next exercise. If so, start the process anew. If not, remind the client where things will start in the next session, noting that you will repeat the just-mastered exercise a few times. Mastered interoceptive exposures can and ought to be assigned as homework.

Troubleshooting Interoceptive Exposure Many cases do not go as smoothly as the generic description in a book. Let’s turn briefly to a few common challenges in conducting interoceptive exposure.

The Client Has a Panic Attack The first challenge is the client has an actual panic attack. After all, you are asking the client to simulate a panic attack. It is plausible that one will be triggered. And, in fact, clients do have panic attacks when engaged in interoceptive exposure. Let’s walk through a few ways to manage this problem. First and foremost, be prepared to be calm. This is easy to say, but more difficult to do. The more you know about how anxiety and panic work in the body, the calmer you can be. Remember that a panic attack, though terrifying for the client, is not dangerous. The body will return to a calm state in a matter of minutes. And as long as you are in safe situation (e.g., an office), nothing dangerous will happen. You may even be able to think to yourself that this is a good sign: that the interoceptive work was producing the exact sensations that the client experiences

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during a panic attack. In other words, a main clinical problem is in the room right now. I will sometimes let the client know that this is my attitude in preparing for interoceptive exposures, saying: “Some clients experience panic symptoms and even panic attacks when doing these exercises. We don’t aim for that—remember we try to move gradually. However, if it does happen, we can see that as a positive. You will be in a safe place. I will be here to support you. And we will get some direct info on what your panic attacks are like and how you cope with them. So I think having a panic attack in session, though not a goal, can be a good thing.” Keeping your body language and voice calm and easy will go a long way. Gentle reassuring words can be helpful: “Looks like you are having a panic attack. We are in a safe place right now. It will be OK. You are safe. I will stay with you while we wait for the attack to end.” You can then calmly help the client engage in some coping. Model and then suggest the client engage in slow and easy breathing. Ask the client to relax different parts of their body: shoulders, legs. Consider engaging in some cognitive coping: “Your heart will slow back down”; “You are getting plenty of oxygen right now”; “We are in a safe place”; “Your body feels out of control but you are OK.” A key here is for you to offer these suggestions slowly and calmly. Panic speeds things up. Your job is to model the opposite of that. You are the parasympathetic nervous system to the client’s sympathetic nervous system. A temptation can be to try to solve the panic attack right now. Resist that temptation and instead make slow and calm suggestions, one at a time, giving each one time to sink in. Remember: the attack will eventually stop on its own. You and the client just have to wait it out. Some clients respond well to hearing how long it has been since the attack started: “It has been 3 minutes.” Others, though, prefer quiet. Until you know your client’s preference, you will have to feel your way through that one. Once the attack has ended, praise the client for their courage (and praise yourself silently too—it is scary to watch another person’s distress). Next, debrief the experience in the same way you would any exposure experience. The experience was an exposure and framing it that way helps the client to conceptualize the experience as part of the treatment process and not just the uninvited, unexpected, and terrifying



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visitor they have come to know. The way to get better usually involves having panic attacks to learn that they are seriously uncomfortable but not life-threatening; they are events with which a client can cope. During the debrief, reflect that the client just experienced one of their worst fears, that it was tough, and that they survived it ably. You may also need to do some damage control. Some clients may associate that interoceptive exercise or therapy itself with panic attacks, leading to cancellations and avoidance. Inoculation can help here via predicting this outcome with the client. My typical way of presenting this involves the back-pocket client strategy—that is, talking about another client (in a deidentified way of course) to present one way things may go. Here is how I have presented it to clients: “I had a client who once had a panic attack in session when we were doing interoceptive exposure. She did great with it—it was scary and she still managed to cope with it. As you might imagine, she was fearful to try interoceptive exposure again. And you may not be surprised to hear she cancelled the next three sessions, always with a good excuse for cancelling. Once she did come back in, we talked over her concerns about continuing therapy and planned to resume the interoceptive exposures slowly. In the end, it turned out great for her. She even had another panic attack in session. But this time, she knew she had to get back on the horse quickly. I say all of this so that you know it may happen that you have a panic attack during these exercises. It does not usually happen, but it can happen. If it does, it will be important to keep coming in to treatment.”

Exercises Are Rated Low Intensity The second challenge is related to exercises that the client rates as relatively low in intensity. Bear in mind that the goal here is to expose the client to sensations that are as intense as the ones they experience during panic attacks. As a result, low-intensity interoceptive exposures may not lead to generalizable mastery. As with any procedure, your first step in the situation is to make sure that the client is doing it “right.” Are they really breathing as heavily as is required—perhaps they could step that up a few levels? Are they running in place quickly enough or could they pick up their pace? If they are doing the exercise correctly, you can increase the time for the exercise. Perhaps another 30 or 45 seconds will get the sensations back into the intense range. Adjust these increases for those exercises that are

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done in briefer intervals, such as breath holding or head shaking. If neither of these works, in most cases, you will proceed with exposure and stop when the anxiety rating settles at or under 2. There are a few other alternatives worth considering, especially if the target exercise is viewed as a key one for the client’s panic attacks. The first alternative is in vivo exposure discussed later in this chapter. It may be that the safety of your session prevents the client from feeling the sensations intensely. Moving the exposures into contexts outside of the office, especially ones in which the client is most fearful, can facilitate more intense (and probably more generalizable) exposure exercises. A second alternative is to use nonphysiological means to increase the intensity. Cognitive strategies can often work to increase the intensity. Essentially, you can encourage the client to think or even state out loud some anxiety-provoking thoughts relevant to the exercise. “What if I my heart starts beating too fast?”; What if I cannot catch my breath?”; What if I start to go crazy?” To the extent possible, use thoughts the client themselves actually has reported before or during panic attacks. These thoughts may lead to an increase in the intensity of symptoms. However, one does need to trek down this path with some caution. Intentionally practicing anxiety-provoking thoughts in the absence of coping thoughts is obviously not the end goal. Learning occurs in patterns and we are not aiming to get those thoughts stuck together with those symptoms. If you do choose this alternative, please consider being clear with the client that the strategy is being used intentionally to make things more intense. You will want to be sure to conduct some cognitive work with the client later to help protect against the rehearsed thoughts encroaching into later exposures (or worse, into later life experiences). Use this alternative sparingly. In most cases, it is better to proceed with a watered-down version of the exposure than to supercharge it with anxiety-provoking thoughts.

Suspect Low Anxiety Ratings Another challenge frequently encountered in interoceptive exposure is failure to see the client’s anxiety rating rise above a 2 even when it was highly anxiety-provoking during the assessment phase. You may be thinking, “Why is that a problem? You just said that is the goal.” OK—you got me there. What I am talking about here are low anxiety ratings that seem fishy to you and not the actual anxiety reduction that we anticipate when conducting exposure. If you assess the situation and determine that the low anxiety is a true indicator of habituation, then



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hurrah! Time to move on. If you determine the decrease in anxiety rating is not actual reduction, then time for some assessment. A main goal will be to assess why the rating is lower than expected. There are several reasons this could occur. As noted with regard to the intensity rating, it is possible that the client is too comfortable in the therapeutic situation. There may be safety signals in your office or about you that put the client at ease and allow them to overlook intense symptoms. This possibility can be a good outcome initially. However, unless you intend to spend the rest of your life hanging out with the client, you will need to help them to learn that they can do the coping without you around. It may be that the client has learned that if they report a low anxiety rating, the exposure stops. This is easy enough to suss out. If the rating is truly low, then repeated exposures over extended periods of time should be no problem. Another possible reason for the low anxiety rating may be that the client is not really engaged in the exercise. Recall that a main goal during interoceptive exercises is to remain focused on the sensations. Clients can use actual physical objects to help them distract, such as the ticking of a clock or the brightness of a light bulb. They can feel the alprazolam capsule in their pocket and know they can stop the feelings at any time by taking the pill. There are any number of possible safety signals to consider that may prevent the client from immersing themselves in the experience. The client can also engage in cognitive distraction, including what may seem like positive thoughts running through their mind, like “I am OK” or “This is not dangerous.” Yes—these are great things to think and they do counter thoughts that speak of the danger of the symptoms. However, they run directly against the point of the exercise—namely, the experience of the sensations in all of their intensity. Distraction can take many forms, including efforts to cope and reduce the intensity and anxiety related to the sensations. You can praise the client for having developed such excellent coping skills. And then you must redirect the client to engage in the exercise without the safety signals or other forms of distraction. And as with the problems with intensity, you may find that the time has arrived to take the exposures on the road. That is where we turn in our next and last section of the chapter.

In Vivo Exposure Related to Panic Disorder Recall that panic attacks and panic disorder may occur in the context of rampant avoidance of situations that may provoke panic attacks or be

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difficult to escape from in case a panic attack happens. Just because a client has mastered the interoceptive exercises does not mean that treatment is over. It is one thing to master the symptoms in a therapy room in the presence of a therapist and quite another to do so in the client’s daily life without the presence of the therapist. As a result, many times in treating panic symptoms, you have to take the exposure show out onto the road. The basic procedures here are about what you would expect. You establish a fear ladder of situations or contexts that the client avoids and then work your way up the ladder using exposure. Employ the same procedure outlined in the basics chapter. The exposures themselves are a bit different than a typical exposure, though, and usually proceed in one of two ways. In the first and most direct way, the client will engage in interoceptive exercises in the contexts. For example, if a client is afraid to attend class due to fear of having panic symptoms, then in vivo exposure involves moving through the interoceptive exercises in a classroom. If the avoided context is a mall, then off to the mall you go. In this approach, the goal is for the client to be in the avoided situation, experience the panic sensations, and eventually habituate. The second way is often used when the first way is viewed as too big a step for the client. Here, you add a set of items to the fear ladder that involve exposure to the situation or context without the addition of the interoceptive exercises. Basically, you build a bridge for the client to reach the first way. For some clients, the situations alone will produce a lot of panic sensations without the need to produce them intentionally. Simply being in the context may be a potent exposure task and one that requires many trials to habituate. However, in most cases, once habituation has been achieved via the second way, it will be important to conduct some in vivo exposures that include interoceptive exposure. Let’s close the chapter by returning to Nile, the 17-year-old male client mentioned at the start of the chapter. After having completed interoceptive assessment and exposure, treatment turned to in vivo exposure conducted at the high school. His fear ladder is shown in Table 10.2. In this session, the client had made it just over halfway up the fear ladder, to being in the guidance counselor’s office. Therapist: Super good job today already! Look where we are— inside the school, school is in session, we are in the guidance counselor’s office. High five, Nile! (High fives.) Nile: OK, I guess.



Exposure for Panic Disorder  193 TABLE 10.2.  Nile’s In Vivo Fear Ladder In classroom, larger class, students there

9

In classroom, small class, students there

8

In classroom, no students

7.5

In school library

7

In guidance office

6.5

In school lobby, typical number of people around

6

In school lobby, no one around

5.5

At front door of school

5

Out of car in parking lot at school

4.5

In car in parking spot at school

4

In car at school parking lot entrance

3.5

In car on street in sight of school

3

In car on road to school

2

Therapist: So, what is your anxiety rating right now. Nile: Pretty up there. Like a 5 or a 6. Therapist: About what we have on the old fear ladder here. OK. So what is the game plan? Nile: I guess we stay here until the anxiety goes down? Therapist: Yes sir. But there is another step. Nile: Right. We have to do those exercises too. Therapist: Right—just like we did in the lobby last time. Nile: S#%&. Therapist: Sounds like you are not looking forward to it. I get that. Let’s see how it goes? Which one did we start with last time? Nile: The straw one. Therapist: OK—here is the straw. What is your anxiety rating now? Nile: About a 7. Getting worse. Therapist: Any thoughts in particular bothering you right now? Nile: Well, I don’t want to have a panic attack. Um. And I don’t want to see anyone I know. I hope no one walks in here.

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Therapist: Good work seeing those thoughts. I made a note of them. We can check back on those later. Final rating? Nile: Still at 7, I guess. Therapist: All righty—let’s start the straw work. Nile: (Hesitates but then puts the straw in his mouth, plugs his nose, and breathes through the straw.) Therapist: Excellent. OK. We will go for 60 seconds this time. (Looks at the watch on her wrist.) And time. How intense? Nile: Like a 5. I am kinda used to doing that. Therapist: How about your anxiety rating? Nile: Still at a 7. Therapist: And your similarity rating? Nile: A 7, I guess, though usually my panic attacks are way more intense. So maybe more like a 5. Therapist: Got it. Let’s check back on those thoughts. Anyone come in? Nile: No. And no panic attack either—yet. Therapist: OK—round 2. Notice a few things about how the therapist engaged with Nile. There is a calm matter-of-factness to her approach. She is nonplussed when he becomes a bit agitated about the situation and when his anxiety rating was high. Nile was an anxious client and she knew by this session where the line was for him. She was able to stay calm despite him becoming frazzled. And, by being calm, she served as an observer and scribe for his experiences. Also notice how she moves the action forward. In exposure, the therapist collaborates with the client but often has to be the catalyst who moves the scene forward. Nile gives the therapist many opportunities to halt the action and wander off down what I call a “side-canyon.” These side-canyons are often tempting little tangents one could take with a client to learn more about them, to assess a new area, or to explore a newfound insight the client has had. In the context of this exposure, the therapist remained firmly on the main canyon trail, acknowledging the client’s interest in the side-canyons, and guiding them forward. Finally, notice how she frames the experience. The example starts with her praising the client, despite his obvious distaste for the situation.



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She regularly focuses on what Nile is doing well and how he is facing his fears, labeling that experience clearly. In this chapter, I covered how exposure is varied for clients with panic attacks and panic disorder. I end the book with this chapter, as panic requires the most adjustment, compared to the other problem areas. For those earlier problems, it was generally a matter of adjusting the basic procedure from Chapter 4 a bit. Here, for panic, a different procedure is introduced, one that resembles the one described in Chapter 4 but that requires a more standardized approach.

FORM 10.1.  Interoceptive Exposure Worksheet INSTRUCTIONS Use the following worksheet to record patient experiences and ratings of the interoceptive exposure exercises. You will preselect several of the following experiences to use in a session. After each repetition, record the patient’s descriptions of their sensations. Then, obtain anxiety, intensity, and similarity ratings. Repeat the same experience multiple times. In many cases, anxiety level will decrease over time and this is the goal for stopping each individual exercise (i.e., repeat until anxiety is reduced). However, in some cases, anxiety reduction may not occur in a significant way. In these cases, the stopping point for each exercise is when the client appears to understand that even though they are experiencing a high level of anxiety, they are still “OK” and “can handle it.”

Typical Interoceptive Exposure Experiences 1. Shake head: Shake head side to side (30 seconds). 2. Quick up: Put head between legs (30 seconds) and then lift it quickly. 3. Run: Run in place or use steps (1 minute). 4. Hold breath: Hold breath as long as possible. 5. Tense: Hold total body tension or hold push-up position (1 minute). 6. Spin: Spin in a swivel chair (1 minute). 7. Hyperventilate: Hyperventilating (1 minute). 8. Straw: Breathe through a straw or as slowly as possible (2 minutes). 9. Stare: Stare at a spot on a wall or at a reflection in a mirror (90 seconds),

Alternative Interoceptive Exposure Experiences 1. For chest pain: Tell the client to take a very deep breath and then hyperventilate. 2. For heat and sweat: Have the client sit in a very hot room (space heaters may be helpful). 3. For throat tightness: Tie a tight scarf, necktie, collar, etc., around the client’s neck. 4. For choking: Place a tongue depressor on the back part of the client’s tongue or place your finger toward the back of the client’s mouth. If the client reports little or no anxiety to any of the exercises, you can repeat any of them with any/all of the following variations: 1. Alone in the office (therapist may be a safety signal), 2. At home alone (getting ratings becomes a challenge, but worth trying). 3. Conduct the exercises while imagining that the client is experiencing the sensations in an anxiety-provoking situation. 196

Date:                Client initials:       

INTEROCEPTIVE EXPOSURE WORKSHEET

Exercise

Sensations

Panic Anxiety Intensity similarity (0–10) (0–10) (0–10)

From Exposure Therapy with Children and Adolescents by Michael A. Southam-Gerow. Copyright © 2019 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details). Purchasers can download an enlarged version of this material (see the box at the end of the table of contents).

197

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Index

Note. f or t following a page number indicates a figure or a table. Academic impairment, 36, 136 Across-trial habituation, 11, 12f. See also Habituation Action phase of an exposure. See also Exposure interoceptive exposure and, 186 intervening in an exposure and, 65–66 overview, 62–67 panic disorder and, 186 taking ratings during, 66–67 Actions, 17–19, 17f All-or-nothing thinking, 90 Alternative scenarios, 174–175 Anticipatory thoughts. See also Expectations interoceptive assessment and, 180 preparation for exposure and, 61–62 Anxiety. See also Panic disorder; Separation anxiety; Social anxiety; Worry avoiding, 2–3 intervening in an exposure and, 63–64 problem-solving skills training and, 97–98

progress monitoring measures and, 49–50 research regarding the treatment of, 1–2 role of, 14–17 when to use skills interventions, 79–80 Anxiety ratings, 66–67. See also Rating exposures Approach progress monitoring measures and, 51 psychoeducation regarding, 21–23 Arbitrary inference, 90 Assertiveness training, 76 Assessment assessing and identifying targets for exposure and, 29–40 interoceptive assessment, 179–185, 179t overview, 28 separation anxiety and, 141–147 social anxiety and, 121–122 social skills and, 123–127 worry and, 164–167 Autonomic nervous system (ANS), 81–82

203

204 Index Avoidance appropriateness of exposure and, 6 downward-arrow technique and, 170 fear ladders and, 35–36 interoceptive exposure and, 182–185, 191 overview, 2–3 panic disorder and, 191–192 progress monitoring measures and, 51 psychoeducation regarding, 19–21 refusals of clients and, 131–134 rehearsal of tasks and, 60

B Behavior, 17–19, 17f Beliefs downward-arrow technique and, 172 worry and, 164–167 Between-trial habituation. See also Habituation action phase of exposures and, 67 measuring progress and, 71–72 Bioinformational theory, 8 Body posture panic attacks and, 188 social anxiety and, 126 Brainstorming solutions, 93–94, 94t. See also Problem-solving skills training Breathing exercises. See also Relaxation skills training breathing retraining, 82–83 interoceptive assessment and, 184–185 panic attacks and, 188

C Caregivers. See also Families conflict between, 147–154 involving in treatment, 30, 136–141 irrational fear versus perceptiveness and, 154–161

separation anxiety and, 141–147 teaching to implement exposures, 138–141 Case conceptualization, 171–172 Catastrophization, 90, 171 Central nervous system (CNS), 81 Clients action phase of exposures and, 62–67 appropriateness of exposure for, 4–7 assessing and identifying targets for exposure and, 29–30 challenges in building fear ladders and, 46–47 debriefing and, 67–71 ground rules for exposures and, 25–26 irrational fear versus perceptiveness and, 154–161 praising, 67–68 preparation for exposure and, 61–62 refusals of, 131–134 separation anxiety and caregivers and, 141–147 when to use skills interventions, 79–80 Cognitive biases, 164 Cognitive distractions, 191 Cognitive restructuring, 85–87, 90–92 Cognitive skills. See also Cognitive skills training; Coping skills interoceptive exposure and, 186–187 overview, 76 panic disorder and, 186–187 phobias and, 106–107 troubleshooting when exposures go awry, 129–131 worry and, 163–167 Cognitive skills training, 85–92, 174–175. See also Cognitive skills; Skills interventions Cognitive triangle, 17–19, 17f, 164

Cognitive-behavioral therapy (CBT) cognitive skills training, 85–92 downward-arrow technique and, 170–172 effectiveness of, 1–2 problem-solving skills training, 92–98, 94t, 95t psychoeducation and, 14 relaxation skills training, 81–85 skills training interventions and, 80 worry and, 175 Comfort zone, 64 Confidence social anxiety and, 122 when to use skills interventions, 80 Confirmatory information, 164–167 Context, 116–120, 123–124 Conversations, 125–126. See also Social skills training Coping modeling, 59–60 Coping skills. See also Cognitive skills; Problem solving; Relaxation; Skills interventions cognitive skills training, 85–92 interoceptive exposure and, 191 overview, 74–75, 76 panic attacks and, 188 problem-solving skills training, 92–98, 94t, 95t relaxation skills training, 81–85 when to use skills interventions, 77–80 Co-sleeping, 153–154 Creativity, 46–47 Crying during an exposure intervening in an exposure and, 64–65 troubleshooting when exposures go awry, 131 Cultural factors, 145

D Danger zone, 64 Debriefing phase of exposures interoceptive exposure and, 186–187 overview, 67–71

Index 205 panic attacks during an exposure and, 189 panic disorder and, 186–187 Diagnosis assessing and identifying targets for exposure and, 29 generalized anxiety disorder (GAD) and, 162–163 panic disorder and, 176 progress monitoring measures and, 50 separation anxiety and, 136 social anxiety and, 108 Dial-it-down/up options, 54–55. See also Tasks for exposures Distraction, 191 Downward-arrow technique, 170–172, 173 Drivers for the fear, 3–4

E Emotion regulation skills, 79–80 Encouragement ground rules for exposures and, 27 interoceptive assessment and, 183 Ending conversations, 126. See also Social skills training Expectations interoceptive assessment and, 180 intervening in an exposure and, 65 preparation for exposure and, 61–62 psychoeducation and, 23–25 Experiential avoidance, 9, 170. See also Avoidance Exposure. See also Fear ladders; In-session exposures; Repeated exposures; Targets for exposure; Tasks for exposures action phase of, 62–67 appropriateness of, 4–7 assessing and identifying targets for, 29–40 caregiver conflict and, 147–154 cognitive skills training and, 86–87

206 Index Exposure (continued) debriefing and, 67–71, 186–187, 189 frequent and repeated approach and, 22 goals of, 9–12, 11f, 12f ground rules for, 25–27, 112–113 measuring progress and, 71–75, 72f, 73f overview, 2–4, 7–9, 19–23, 52–53 panic attacks during, 187–189 panic disorder and, 176–177, 185–195, 193t practicing for unexpected scenarios, 113–115 preparation for, 53–62, 69–71 problem solving in, 97–98 relaxation and, 81 teaching caregivers to implement, 138–141 therapist concerns regarding, 4 troubleshooting when exposures go awry, 127–134, 187–191 worry and, 172–175 Exposure lifestyle, 10

F Families. See also Caregivers assessing and identifying targets for exposure and, 36 caregiver conflict and, 147–154 ground rules for exposures and, 26–27 involving in treatment, 30 irrational fear versus perceptiveness and, 154–161 separation anxiety and, 141–147 teaching to implement exposures, 138–141 Fear ladders. See also Exposure; Monitoring; Tasks for exposures building, 40–49, 42f, 50t challenges in building, 46–49 interoceptive exposure and, 185–186

involving caregivers in treatment of separation anxiety and, 137 number and spacing of rungs, 40–43, 42f, 45–46, 47–48 overview, 34–36 panic disorder and, 185–186, 192–195, 193t phobia and, 100–102 psychoeducation and, 23 rehearsal of tasks and, 57–60 selecting and ordering the items on, 43–45 social anxiety and, 110–111 Fear of failure, 171–172 Fear Survey Schedule for Children— Revised (FSSC-R), 31–32 Fear system, 14–17 Fears. See also Fear ladders; Phobia appropriateness of exposure and, 6–7 assessing and identifying targets for exposure and, 31–34 assessing reasons for, 37–39 downward-arrow technique and, 171–172 drivers for, 3–4 hierarchical ratings of, 34–36 interoceptive assessment and, 182–183 overview, 2–3 Feelings, 17–19, 17f Fight-or-flight system, 14–17 Flooding, 23 Foa, Edna, 8 Freezing during an exposure, 65

G Generalized anxiety disorder (GAD). See also Worry cognitive-behavioral therapy (CBT) and, 175 overview, 162–163 when to use skills interventions, 79 worry triage and, 169



Index 207

Goals. See also Targets for exposure building fear ladders and, 41–42 expectations and, 23 Gradual exposure phobias and, 102–105 psychoeducation regarding, 23 Greetings, 124–125. See also Social skills training Ground rules for exposures, 25–27, 112–113 Guided imagery, 83–85. See also Relaxation skills training

overview, 185–191 panic disorder and, 177 troubleshooting when exposures go awry, 187–191 Interoceptive Exposure Worksheet, 185–186, 196–197 Intervening in an exposure, 63–66, 187–188

H

K

Habituation action phase of exposures and, 67 interoceptive exposure and, 187, 190–191 measuring progress and, 71–75, 72f, 73f overview, 10–12, 11f, 12f panic disorder and, 187 Hierarchical ratings of fears, 34–36. See also Fear ladders Home-based sessions involving caregivers in treatment of separation anxiety and, 137 teaching caregivers to implement exposures and, 138–141

Kozak, Michael, 8

I Imaginal exposure, 172–174. See also Exposure In vivo exposure. See also Exposure panic disorder and, 190, 191–195, 193t worry exposure and, 174 In-session exposures. See also Exposure involving caregivers in treatment of separation anxiety and, 137 social anxiety and, 109–120 Interoceptive exposure. See also Exposure interoceptive assessment and, 179–185, 179t

J Jones, Cover, 7–8

L Learning building fear ladders and, 41–42 frequent and repeated approach and, 22 goals of exposure and, 10 preparation for exposure and, 62 Learning zone, 64

M Mastery, 9, 59–60 Medical considerations, 177 Mind reading, 90 Mindfulness approaches, 76, 85. See also Relaxation skills training Monitoring, 28. See also Fear ladders; Progress monitoring Multidimensional Anxiety Scale for Children (MASC), 50

N Name, Normalize, Empathize, and Encourage (N2E2) technique, 183, 184 Nonverbal communication, 126

O Overgeneralization, 90

208 Index

P Panic attacks. See also Panic disorder overview, 176 troubleshooting when exposures go awry, 187–189 in vivo exposure and, 192–195, 193t Panic disorder. See also Anxiety interoceptive exposure and, 179–191, 179t overview, 176–177 psychoeducation regarding, 177–178 troubleshooting when exposures go awry, 187–191 in vivo exposure and, 192–195, 193t Parasympathetic nervous system, 81–82 Parents. See Caregivers; Families Perfectionism, 118, 121–122 Phobia. See also Fears fear ladders and, 100–102 graduation exposure and, 102–105 overview, 99–100 Physiological anxiety. See also Anxiety interoceptive assessment and, 179–185, 179t when to use skills interventions, 79–80 Practicing tasks, 57–60, 113–115. See also Rehearsal; Tasks for exposures Praise debriefing phase of exposures and, 67–68 panic attacks and, 188–189 panic disorder and, 194–195 Preparation for exposure. See also Exposure debriefing phase of exposures and, 69–71 guesses about how exposure may go and, 61–62 overview, 53–62

Problem definition, 93, 94t, 95t. See also Problem-solving skills training Problem solving. See also Coping skills; Problem-solving skills training overview, 76 troubleshooting when exposures go awry, 128 worry triage and, 168–169 Problem-solving skills training, 92–98, 94t, 95t. See also Problem solving; Skills interventions Progress monitoring. See also Monitoring fear ladders and, 48–51, 50t overview, 28, 71–75, 72f, 73f standardized measures for, 49–51 Progressive muscle relaxation (PMR), 83. See also Relaxation skills training Psychoeducation cognitive triangle information, 17–19, 17f expectations and, 23–25 exposure therapy information, 19–23 fear system information, 14–17 ground rules for exposures and, 25–27 overview, 14 panic disorder and, 177–178

R Rating exposures. See also Exposure; Tasks for exposures action phase of exposures and, 66–67 debriefing phase of exposures and, 68 interoceptive exposure and, 180–182, 186–187, 189–191 measuring progress and, 71–75, 72f, 73f

overview, 56–57 panic disorder and, 186–187, 192–195 worry exposure and, 173–174 Refusals of clients. See also Avoidance interoceptive assessment and, 184 school refusals, 150–152 social anxiety and, 131–134 Rehearsal, 57–60. See also Practicing tasks; Tasks for exposures Reinforcement avoidance and, 19–21 refusals of clients and, 131–132 Relaxation, 76, 79–80. See also Coping skills Relaxation skills training. See also Skills interventions interoceptive exposure and, 184–185, 186–187 overview, 81–85 panic attacks and, 188 panic disorder and, 186–187 Repeated exposures. See also Exposure debriefing phase of exposures and, 69–71 interoceptive exposure and, 187 measuring progress and, 71–75, 72f, 73f panic disorder and, 187 psychoeducation regarding, 22 Revised Children’s Anxiety and Depression Scale (RCADS), 49

S Safety ground rules for exposures and, 27 interoceptive exposure and, 182–183, 191 intervening in an exposure and, 63–66 panic disorder and, 187–188 troubleshooting when exposures go awry, 187–188

Index 209 Scale for Children’s Anxiety and Related Emotional Disorders (SCARED), 49–50 School functioning, 36, 136, 150– 152 School refusal, 150–152. See also Refusals of clients; Separation anxiety Selective abstraction, 90 Selective attention, 164–167 Selective mutism, 126 Separation anxiety. See also Anxiety caregiver conflict and, 147–154 compared to child perceptiveness, 154–161 involving caregivers and, 136–141 irrational fear versus perceptiveness and, 154–161 overview, 135–136 Separation anxiety disorder (SAD), 136. See also Separation anxiety Skills interventions. See also Coping skills; Social skills training cognitive skills training, 85–92 overview, 80–98, 94t, 95t problem-solving skills training, 92–98, 94t, 95t relaxation skills training, 81–85 when to use, 77–80 Slowing down the exposures, 132–133 Social anxiety. See also Anxiety overview, 108–109, 120–123 social skills and, 123–127 troubleshooting when exposures go awry, 127–134 Social skills, 123–127. See also Social skills training Social skills training. See also Skills interventions overview, 76 social anxiety and, 124–127 troubleshooting when exposures go awry, 127–134 when to use, 78–79

210 Index Solution brainstorming, 93–94, 94t. See also Problem-solving skills training Specific phobia. See Phobia Stimulus assessing and identifying targets for exposure and, 31–34 involving caregivers in treatment of separation anxiety and, 137 overview, 7–8 phobia fear ladders and, 100–102 Sympathetic nervous system (SNS), 14–15

T Talking to a client during an exposure, 65–66 Targets for exposure. See also Exposure; Goals; Tasks for exposures assessing and identifying, 29–40 social anxiety and, 109–120 Tasks for exposures. See also Exposure; Fear ladders; Targets for exposure action phase of exposures and, 62–67 building fear ladders and, 40–49, 42f, 50t clarifying, 55–56 making tasks easier, 133–134 phobias and, 105 rating, 56–57 refusals of clients and, 131–134 rehearsal of, 57–60 selecting, 53–55, 134 slowing down the exposure, 132–133 Therapists action phase of exposures and, 62–67 ground rules for exposures and, 27 as observers during an exposure, 63–66

rehearsal of tasks and, 57–60 when to use skills interventions, 80 Thought identification, 87–90. See also Cognitive skills training Thought investigation, 85–87, 90–92. See also Cognitive skills training Thoughts cognitive skills training and, 85–92 cognitive triangle information and, 17–19, 17f panic disorder and, 190 worry and, 163–167 Time management in sessions, 60 Transfer of control social anxiety exposures and, 112 teaching caregivers to implement exposures and, 138

V Video-based exposures interoceptive assessment and, 180 taking ratings during, 66–67

W Within-trial habituation. See also Habituation action phase of exposures and, 67 measuring progress and, 72–74 overview, 11, 11f Worry. See also Anxiety; Generalized anxiety disorder (GAD) cognitive strategies and, 163–167 downward-arrow technique and, 170–172, 173 exposure and, 172–175 functionality of, 164–167 irrational fear versus perceptiveness and, 154–161 overview, 162–163 when to use skills interventions, 79 worry triage, 167–169, 169f

Z Zone of proximal development, 64