Based on Questions from our Webinar!

Here is an initial sampling of research based on some of the things I discussed. I do not want to overwhelm because there is a lot – this is just a few pieces I brought together for based on some of the questions that came up during our webinar. 

Again, there are no hard and fast rules about always/never – all the strategies I discussed may be useful in some instances. The point is to think critically about the strategies and how they apply for any client you are working with and not blindly accept them. We do, however, no matter what we do, want to ensure success. So, we do go where we believe our clients can be successful. But we cannot automatically assume they won’t be successful with more difficult tasks. I always show confidence they can do the hardest task – we just need to get them motivated to try.

It is essential you know a) potential pitfalls/anxiety traps and where we might be reinforcing the “I can’t handle it” story and b) what skills need to be taught and if the strategy you are using is helping to build that skill (or promoting avoidance or the anxiety story etc.).

With habituation, for example, the traditional approach is to tell the client that an exposure session will end once the anxiety has gone down and that we must wait until much later in treatment to work on more difficult things because you are not ready yet. While habituation can be helpful, the problem is when we over rely on fear reduction, as it can have unintended negative consequences for some clients.

Habituation is a natural process that often happens anyway - we just don't need to try to force it by making that the goal. That's where it becomes a problem.

Examples of reviews discussing how habituation is not a reliable predictor of positive outcomes:

Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A.

(2008). Optimizing inhibitory learning during exposure therapy. Behaviour research and therapy, 46(1), 5–27.

Jacoby, R. J., & Abramowitz, J. S. (2016). Inhibitory learning approaches to exposure therapy: A critical review and translation to obsessive-compulsive disorder. Clinical psychology review, 49, 28–40.

And where habituation can become a problematic safety behaviour in and of itself (and therefore reinforcing anxiety):

Craske, M. G., Liao, B., Brown, L., & Vervliet, B. (2012). Role of Inhibition in Exposure Therapy. Journal of Experimental Psychopathology, 322–


And reinforce the story that, when they do feel anxious, they are a failure, which can cause premature termination or relapse, which is addressed above and:

Abramowitz, J.S., & Arch, J.J. (2014). Strategies for Improving Long-Term Outcomes in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder: Insights From Learning Theory. Cognitive and Behavioral Practice, 21, 20-31.

Other examples of how successful outcomes can occur without habituation

Meuret, A. E., Seidel, A., Rosenfield, B., Hofmann, S. G., & Rosenfield, D. (2012). Does fear reactivity during exposure predict panic symptom reduction?. Journal of consulting and clinical psychology, 80(5), 773–785.

It is more about process and critical to ensure you do not misinterpret habituation 

Benito, K. G., & Walther, M. (2015). Therapeutic Process During Exposure: Habituation Model. Journal of obsessive-compulsive and related disorders, 6, 147–157.

And the trouble of trying to relax when our alarm system is rung

Moulding, R., & Kyrios, M. (2006). Anxiety disorders and control related beliefs: the exemplar of Obsessive-Compulsive Disorder (OCD). Clinical psychology review, 26(5), 573–583.

The focus is more on experiencing, tolerating, and even accepting the feelings, such as any of the work you may find in DBT and ACT (e.g., Schmidt, Mitchell etc. 2011, Twohig et al., 2015)

As for fear ladders/exposure hierarchies, which is an old, traditional approaches, only impedes extinction long term (though certainly may help short-term fear) and perpetuates worries about worrying in the first place. Therefore, a fear list or exposure list is better used so we don’t have to worry about the levels or assume a gradual list – there is so much more flexibility in this regard. You choose whichever seems most productive. This is not new, as there have been researchers demonstrating this for years:

Bjork, R. & Bjork, E. L. (2006). Optimizing treatment and instruction: Implications of a new theory of disuse. IN L. G. Nilsson & N. Ohta (Eds), Memory and society: Psychological perspectives. 116-140. Psychology Press.

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: an inhibitory learning approach. Behaviour research and therapy, 58, 10–23.

Culver, N. C., Stoyanova, M., & Craske, M. G. (2012). Emotional variability and sustained arousal during exposure. Journal of behavior therapy and experimental psychiatry, 43(2), 787–793.

Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., Yi, R., & Craske, M. G. (2012). Challenges to the traditional exposure paradigm: variability in exposure therapy for contamination fears. Journal of behavior therapy and experimental psychiatry, 43(2), 745–751.

The only real benefit to extinction hierarchies shown is to prevent premature termination – but if you are doing the right steps from the Anxiety Compass, treatment refusal will never happen because you are working collaboratively with the child/teen and ensuring they are motivated to do the work in the first place. We never force children/teens to do anything they don’t want to! It’s their choice.

We know that combining multiple fear cues, which I also discussed in the webinar, helps maximize client success – something that was established over 25 years ago (e.g., Bjork, 1994) – and helps deepen extinction (Rescorla, 2006).

Bjork, R. A. (1994). Memory and metamemory considerations in the training of human beings. In J. Metcalfe & A. P. Shimamura (Eds.), Metacognition: Knowing about knowing (pp. 185–205). The MIT Press.

Rescorla R. A. (2006). Deepened extinction from compound stimulus presentation. Journal of experimental psychology. Animal behavior processes, 32(2), 135–144.