Acceptance and commitment therapy–enhanced exposures for children and adolescents

C H A P T E R

17 Acceptance and commitment therapy enhanced exposures for children and adolescents Anna E. Allmann1, Lisa W. Coyne2, Rebecca Michel2 and Robert McGowan3 1

Columbia University Clinic for Anxiety and Related Disorders, Columbia University, Tarrytown, NY, United States, 2McLean OCD Institute for Children and Adolescents, Harvard Medical School, Middleborough, MA, United States, 3The University of Scranton, Scranton, PA, United States

I can’t do that exposure, it’s too hard. I don’t think this exposure task is making me anxious enough. Because this exposure is happening in treatment and not in my real life it won’t work. You’re asking me to do the scariest thing I can imagine doing; it feels impossible!

As an exposure and response prevention (ERP) therapist, these are just a few of the apprehensions you may hear while working with children and adolescents with anxiety disorders. As you will discover, acceptance and commitment therapy (ACT) may be an effective adjunctive tool to address some of the common responses to the first-line treatment for anxiety disorders, ERP. As a clinician, you are likely very aware of the staggering rates of anxiety disorders and symptoms in youth. A meta-analysis found the worldwide prevalence of any anxiety disorder in childhood and adolescence was estimated at 6.5% (Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015). Additionally, given the high 3-month prevalence rates of anxiety disorders in youth (Costello, Mustillo, Erkanli, Keeler, &

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Angold, 2003; Merikangas et al., 2010) it is one of the most likely presentations to walk into your office. Generally, we understand anxiety disorders as based in avoidance behaviors. In order to avoid anxiety or discomfort, individuals may refuse to attend school, avoid their homework, remove themselves from friendships or social gatherings, or fail to engage in healthy interpersonal relationships. At severe levels, adolescents may become trapped in one room of their house, or even one spot on a couch, for hours, days, or weeks at a time in an effort to avoid any possible contact with their anxiety. These avoidance behaviors have manifold implications for emergent adolescents and can derail youth from appropriate developmental trajectories. Parents and siblings are also often participants, albeit unwillingly, in the child’s efforts to manage or avoid anxiety. In the family context, parents can become enmeshed in coercive patterns with their children that include bribery or threats, or alternately, parents can take on the role of emotion regulation and accommodation of anxious behaviors for their children. Each of these patterns can exacerbate the intensity and duration of an adolescent’s avoidant coping (Wood, McLeod, Sigman, Hwang, & Chu, 2003). ERP treatment seeks to reduce avoidance behaviors and to increase effective distress tolerance, thereby allowing youth to resume participating in their lives and meeting developmental milestones. Unsurprisingly, asking a young person to engage in a situation that is perceived as tremendously scary or dangerous and that was previously avoided is often difficult both for the child and for the child’s family members to accept or be willing to try. While the work of ERP may feel intolerable for some, significant research exists supporting its use to treat anxiety disorders, particularly in adults (Deacon & Abramowitz, 2004; NICE, 2006). Although fewer studies exist evaluating the efficacy of ERP to treat children and adolescents with anxiety disorders, some studies do establish that the effects in adults also generalize to youth (Higa-McMillan, Francis, RithNajarian, & Chorpita, 2016), and it remains the treatment of choice for many practitioners using evidence-based techniques. Despite ERP’s reputation as a gold standard of treatment, as with any treatment modality, some common challenges may arise in practice ranging from treatment refusal to the use of distraction, with significant variability from person to person. Even when implemented properly, some individuals are deemed treatment nonresponders or are unwilling to experience and tolerate the intense anxiety that ERP may elicit. Complementary third-wave cognitive-behavioral approaches such as ACT when employed in combination with ERP treatment may increase treatment willingness, flexibility, adherence, and overall symptom reduction. In this chapter, we describe how ACT can be integrated with ERP to optimize outcomes. We begin by briefly discussing current best

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practices for utilizing ERP. We then provide an introduction to ACT, review the evidence for integrating ACT into ERP, discuss the importance of effectively integrating the family into the work, and offer specific examples and sample treatment plans with corresponding exposure tasks that are both ACT and ERP consistent. We frame all of this discussion from the perspective that ERP is on its own an effective, often transformative tool; however, ACT may enhance its effects, shape willingness and flexibility, and increase an individual’s readiness to tolerate the distress commonly associated with ERP.

Current best practices: A brief overview of exposure and response prevention The fundamental principle of exposure treatment involves encouraging clients to approach and engage with a stimulus that elicits a fear response but that objectively is unlikely to cause actual harm. The second premise of ERP is to prevent a ritual, thought, or behavior that functions to reduce anxiety in the presence of a feared stimulus. These rituals, avoidance, or safety behaviors may decrease anxiety in the short term, but research suggests they actually maintain the fear structure long term and may strengthen associations between the fear and the stimulus (Foa, Steketee, Grayson, Turner, & Latimer, 1984). For that reason, the RP portion of ERP is often referred to as the most important aspect of effective treatment. The ERP approach may sometimes also include imaginal or scripted exposures in instances that cannot safely be experienced. Previous theories posit that when exposure therapy works it is due to breaking conditioned fear responses via habituation and desensitization; however, the mechanisms of action for ERP treatment are becoming more clear as studies emerge suggesting that model may not “carve nature at its joints” exactly (see Vinograd & Craske in this volume). In its place, inhibitory learning is emerging as a viable theory, which proposes that instead of fear being extinguished by learning new associations with a feared stimulus, these new associations actually compete with, or inhibit, the older learned fear information (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). This has important implications for treatment, including that the goal is no longer to gradually habituate to a feared stimulus, although that may occur, but rather to generate new learning that can compete with an individual’s preexisting fear associations. Notably, downward extensions of this work to children and adolescents are just beginning to emerge, with some evidence still arguing in favor of habituation (Benito et al., 2018). Either way, this

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information becomes highly salient as one considers whether and how to integrate ACT principles alongside ERP. In general, inhibitory learning approaches conceptualize exposure in terms of respondent and operant conditioning theory. When an individual is presented with a feared stimulus in the absence of the feared consequence (e.g., petting a dog without getting bitten), new inhibitory pathways are solidified in which an individual learns that he/she can experience feared thoughts without the corresponding feared events occurring (i.e., expectancy violations). This new learning is challenging for individuals with anxiety and obsessive compulsive disorder (OCD) to access, as they appear to have deficits in this type of learning task (Greisberg & McKay, 2003), which may require additional trials to encode the new information. Additionally, inhibitory learning principles suggest that individuals can acquire flexible and more adaptive ways of behaving in the presence of feared stimuli (e.g., instead of washing hands repeatedly after touching a doorknob, the individual may choose to continue with his or her day, thus creating a new behavioral repertoire when faced with feared cues). Current research suggests that building a hierarchy and using subjective units of distress (SUDs) are helpful in treatment to a degree, but that treatment may be more effective and generalize to the client’s life more readily when therapists do not follow a strict hierarchy, but rather combine exposures to multiple feared stimuli of varying degrees of difficulty while not relying on the reduction of SUDs during the exposure session as a measure of treatment success (Craske et al., 2008). Treatment that does not follow an organized hierarchy more closely mimics life in that exposures to feared situations outside of the therapy office are frequently unpredictable. The sitting with uncertainty that is required when not following a strict hierarchy may be one mechanism to facilitate generalizing what is learned in ERP to the client’s own life. Importantly, habituation also does not appear to predict treatment outcome, according to the adult literature (Craske et al., 2008). The movement away from reducing SUDs as a treatment goal is reflective of the literature demonstrating that inhibitory learning rather than habituation is an active ingredient in successful ERP therapy (Craske et al., 2008, 2014). Therapists can measure a client’s willingness to experience anxiety at any given moment and observe a client’s increase in flexible functioning in the presence of an anxiety-provoking stimulus, which we will learn is also ACT consistent. Consistent with inhibitory learning, therapists can and should still use SUDs to emphasize expectancy violations (thinking an exposure will be harder or easier than it was in practice). The revamped ERP treatment, despite its reduced emphasis on SUDs or a hierarchy, still requires individuals to confront their most feared

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situations as a core principle of change. Requesting that young clients engage in this type of treatment without the expectation that their anxiety will be reduced while also not permitting the use of maladaptive coping mechanisms (safety behaviors and rituals) is not a particularly inviting petition. These challenges with ERP account for much of the criticism it receives, and are also compelling reasons to integrate ACT.

What is acceptance and commitment therapy? ACT is a cognitive-behavioral approach to psychopathology that was developed nearly 30 years ago and is founded on basic research on human language processes and verbal behavior. Broadly, ACT targets the functions of behaviors, thoughts, and emotions in maintaining patterns that are not helpful to the individual in pursuing his or her values or goals. ACT furthermore aims to increase psychological flexibility, or an individual’s willingness to explore utilizing different behavioral, emotional, or cognitive repertoires when faced with life stressors or feared stimuli. Using the ACT approach successfully requires momentto-moment mindfulness on the part of the therapist as to the function of each behavior or thought in maintaining or undermining an individual’s ability to pursue their values and to behave flexibly in the presence of feared stimuli. ACT is broadly comprised of six core processes that promote psychological flexibility and well-being. These processes are acceptance, cognitive defusion, and awareness of the present moment, self as context, values, and committed action. Acceptance refers to an individual’s ability to allow unwelcome experiences (often internal) to be present without attempting to alter, control, or avoid them. As in cognitive behavior therapies (CBT’s) classic Chinese finger trap example (i.e., the harder you try to pull your fingers out, the more stuck they become, and only by moving your fingers inward can you be released), these control strategies often serve to increase the unwelcome experience rather than effectively diminish it. Cognitive defusion is a process of literal “de fusing” from thoughts or feelings that hook or trap people into unhelpful patterns. We can also think of defusion as adjusting the way we relate to our thoughts and emotions. Instead of letting seductive thoughts or feelings control us, we learn to observe them nonjudgmentally and to notice them without feeling compelled to act on them. Present moment awareness is relatively self-explanatory and refers to purposefully attending to current events, both internal and external, as opposed to focusing on the past or the future. Mindfulness and present moment awareness are closely linked processes. Self as context refers

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to the idea that every person maintains a fundamental sense of self that is stable and consistent upon which the inconsistencies of day-to-day life can be observed, including rapidly changing inner experiences such as emotions and thoughts. Values are akin to cardinal directions, in that they shape behaviors, but are not achievable destinations. We can take steps toward our values, but will never arrive due North. Finally, committed actions are the specific behaviors taken to move an individual toward his or her values. The spirit of these six processes, when utilized by a skilled ACT therapist, is seamlessly woven into the dialogue of the therapy session, and can be used to great effect to shape an individual’s willingness to approach and engage in ERP treatment rather than continued avoidance. As such, ACT is a transdiagnostic approach, but is also readily applied to anxiety disorders and used in conjunction with ERP approaches.

The evidence for acceptance and commitment therapy and acceptance and commitment therapy1exposure and response prevention approaches To date, a handful of meta-analyses examining ACT or ACT constructs (e.g., mindfulness, acceptance) and their association with anxiety and OCD-spectrum disorders exist. A 2014 meta-analysis explored (1) the relationship between psychological flexibility and anxiety and (2) reviewed evidence for ACT with anxiety and OCD-spectrum disorders in adolescent and adult samples (Bluett, Homan, Morrison,

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Levin, & Twohig, 2014). Sixty-three studies met inclusion criteria for the meta-analysis of the association between experiential avoidance and general anxiety symptoms. Of these, 14 included samples of adolescents and young adults (college students). Experiential avoidance was associated with both general and disorder-specific measures of anxiety, including OCD. With regard to the meta-analysis of randomized controlled trials (RCTs) evaluating ACT for anxiety disorders, nine studies (n 5 404) met inclusion criteria (Twohig et al., 2018). Results suggested a nonsignificant small effect size (g 5 0.40, 85%; confidence interval [CI] 5 20.16, 0.96, z 5 1.40, P 5 .16, k 5 9; of note, there was significant variability across studies; Q 5 50.32, df 5 8, P , .001), indicating that ACT fared well relative to comparison conditions (e.g., wait-list, other CBT manualized treatments; Bluett et al., 2014). A meta-analysis of lab-based studies evaluating components of ACT found large effect sizes for defusion, present moment awareness, acceptance, and values (Levin, Hildebrandt, Lillis, & Hayes, 2012), relative to control components, highlighting the clinical utility of these as treatment targets. Modest support was found for psychological flexibility with anxiety only. Additional studies evaluate OCD-spectrum disorders such as trichotillomania, skin picking, and tic disorders. The authors of those studies concluded that, while the efficacy of ACT is comparable to that of CBT, and exposure is first-line treatment, ACT processes may be able to increase willingness to do ERP (e.g., Reid et al., 2017), and ACT interventions may be a more precise way of teaching HOW to do ERP (Bluett et al., 2014). There is a smaller emerging literature evaluating ACT for anxiety and/or OCD in children and adolescents. In a 2015 systematic review by Swain, Hancock, Dixon, and Bowman (2015), only four treatment studies for pediatric anxiety and OCD-spectrum disorders met criteria (Armstrong, Morrison, & Twohig, 2013; Fine, Walther, Joseph, Robinson, Ricketts, & Bowe et al., 2012; Franklin, Best, Wilson, Loew, & Compton, 2011; Yardley, 2012). With regard to scientific rigor, as rated on Ost’s (2008) psychotherapy outcome study methodology rating form (POMRF) scale one study was rated “well above average” (Franklin et al., 2011), two were found to be “above average” (Armstrong et al., 2013; Yardley, 2012), one was “below average” (Fine et al., 2012), and one “well below average” (Brown & Hooper, 2009). All studies showed improved outcomes; in Franklin et al. (2011), ACT was comparable to HRT for trichotillomania with regard to self-rated symptom reports. Lønfeldt, Silverman, and Esbjørn (2017) conducted a systematic review and meta-analysis of “third-wave” approaches (i.e., mindfulness-based cognitive therapy, ACT, and metacognitive therapy) for youth anxiety. The goal of the study was to estimate the mean effect sizes for the

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association of third-wave constructs and child anxiety. They found a moderate effect size for mindfulness, a medium to large effect size for metacognitions, and a large effect size for psychological inflexibility (Lønfeldt et al., 2017). Since 2015, 10 studies on ACT for anxiety and/or OCD-spectrum disorders in children and adolescents have been published; of these, 5 were treatment studies. The largest and most rigorous was by Hancock et al. (2018) who conducted an RCT comparing group-based ACT and CBT treatment versus a wait-list control with parents and adolescents with anxiety aged 12 17 (Hancock et al., 2018). Youth in both conditions experienced a clinically meaningful reduction in symptoms, and ACT was comparable to CBT. Additionally, Azadeh, Kazemi-Zahrani, and Besharat (2015) conducted a small RCT comparing ACT to a wait-list control in a sample of female adolescents with social anxiety disorder. Results indicated that compared to the control group, participants in the ACT group reported significantly improved interpersonal functioning and psychological flexibility. A small body of research also exists suggesting that ACT with parents may be a viable route for treatment as well. A recent open trial evaluated the feasibility of a six-session ACT protocol for parents of children with anxiety or OCD (ACT-PAC; Coyne & Moore, 2015). Twenty-three parents (20 mothers, 3 fathers, mean age 45) of children ages 7 17 with a primary anxiety disorder diagnosis (14 males, 9 females; mean age 13 years) participated in the study. Results suggested that the intervention may decrease parents’ cognitive fusion, allowing them to approach their thoughts about their child’s anxiety disorder in a more psychologically flexible way. Results also indicated that the intervention may reduce children’s internalizing (anxiety and depression) and generalized anxiety symptoms (Levitt, Hart, RafteryHelmer, Graebner, & Moore, 2018). Although preliminary findings regarding ACT efficacy with youth must be interpreted cautiously, they represent a compelling rationale for further study. As such, ACT may be a feasible and comprehensive approach to anxiety and OCD. Certainly more robust examination with larger samples and longer follow up windows is warranted. Taken together, this body of empirical work along with clinical observation suggests that children and adolescents may benefit when ACT is integrated into exposure therapy. When encountering youth who are unable or unwilling to experience and tolerate the intense anxiety that comes with exposure, therapists may find these intervention techniques have particular value for enhancing willingness, flexibility, adherence, and overall symptom reduction. In the sections that follow, we describe in more detail what this might look like in practice.

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How to integrate acceptance and commitment therapy with exposure and response prevention for children and adolescents with anxiety disorders Setting the groundwork for effective treatment Psychoeducation Once an appropriate case conceptualization is complete and data regarding the anxiety disorder diagnosis are gathered, the first few sessions of treatment may focus on psychoeducation and providing a rationale for treatment. Orienting the client to the ACT and ERP model often allows the client to feel hopeful about the prognosis and the efficacy of treatment. While introducing any or all of the six components of ACT can be effective during psychoeducation with both parents and youth depending on the individual case, three in particular may be most relevant to setting the stage for successful treatment: values, cognitive defusion, and acceptance. Values

Exploring values with the children and adolescents early in treatment can be an excellent method of building rapport as it is often an inherently enjoyable activity that clarifies one’s sense of self. Furthermore, discussing values and imagining what life would look like “if therapy worked” also may motivate the client to engage in challenging ERP tasks. One domain where ACT informed ERP diverges from classic ERP is that the exposure tasks are chosen based on values, with the ultimate goal being that the client is able to engage in a valued and meaningful life despite the presence of unwanted internal experiences such as anxiety. The emphasis here is on optimizing functioning rather than identifying the most feared stimuli that may or may not relate to the client’s ability to function or engage in committed actions. Encouraging the client to identify (1) What is valuable and important to him/her and (2) ways that his/her symptoms are currently posing barriers to moving toward those stated values, can bring into focus the importance of treatment and allow the client to recognize that treatment is not a discrete action with a beginning and an end, but rather an ongoing process that can be continued in pursuit of one’s goals even once formal treatment is concluded. ACT is readily adapted for children and adolescents as many of its tenets are based in metaphors. For example, a provider may use the passengers on the bus exercise (Hayes, Strosahl, & Wilson, 1999) when working with adolescents on identifying values and the myriad ways obsessional thinking can inhibit movement toward those

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values. This exercise asks the client to imagine that he/she is driving a bus toward his/her stated values and rowdy passengers are jeering and distracting (obsessions) him/her from the important task of driving. The passengers may even instruct the driver where to go or what to do, but the client’s job is to continue driving the bus in the desired direction with the disruptive thoughts and obsessions along for the ride. Subsequently, we highlight some of the language we like to use in treatment sessions to introduce the concept of values with youth: Therapist: “In today’s session, I want to do something a little different. Instead of only talking about the scary stuff or problems in life, I want to focus on what makes you you. Why do you want to get up in the morning? What makes you feel alive? What makes you tick? Setting aside what parents, friends, teachers, or even therapists think, I want to get to know what you value or find important. Any thoughts right away?” At this point, often children and adolescents will disclose a number of areas of life they find exciting or that give them joy; however, some clients are more reserved and will require coaxing. If that is the case, the therapist can choose from a variety of exercises such as the Yearbook exercise (adapted here from the more commonly known Tombstone exercise), or discussing a favorite movie, but there are certainly others that can be used as well. Below are examples of how these sessions might look: Yearbook exercise—picking up where the previous dialogue ended

Client

“No, I don’t really know what’s important to me, so much of my life has been about my anxiety, and I can’t really imagine life without it.”

Therapist

“That’s okay, that happens. Anxiety is kind of a jerk in that it often tries to take away from us the stuff we like the most. To get us started thinking about what you value, I have an exercise. Now, it may seem a little weird, but stick with me. It’s called the Yearbook exercise, and I want you to imagine how you would want to be remembered by friends and family when you’re graduating high school. What would you want written in your yearbook or as your superlatives? Some people say things like “I want to be remembered by being a good friend,” or “being funny,” but I want you to think about what is most important for you that others remember. Go ahead and jot down some ideas when you’re ready.”

Provide the client a piece of paper. When individuals continue to struggle to identify values, we may use a more abstract technique like discussing a favorite movie, as below.

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Favorite movie exercise (can substitute book or TV show)—picking up where the previous dialogue ended

Client

“I still can’t really think of anything. I don’t know how I want to be remembered or what’s important to me. I guess I just don’t think about this stuff much.”

Therapist

“Okay, let’s shift gears. I get that this can feel pretty overwhelming talking about all these big concepts like values, so instead, why don’t you tell me a little about yourself. Do you have a favorite movie or favorite character in a movie?”

Client

“There is this one movie, “The Perks of Being a Wallflower”, I really like that one.”

Therapist

“That’s a great movie. What made you pick it though? What do you like most about it?”

Client

“Well, I’m not sure really. I guess I like seeing how close the friends are, and that they are kind of the ‘different kids’ in school, but still found each other.”

Therapist

“So it sounds like you might value friendship?”

Client

“Yeah, I guess so. And the music was pretty good too, yanno how it wasn’t so mainstream. I liked that it felt like being different was okay.”

Therapist

“That makes a lot of sense. I really liked those parts of the movie too. So maybe you value acceptance or tolerance? And it sounds like you enjoy music.”

In this way, the therapist begins connecting for the client their interests and hobbies with their values. The next step, once values are identified, is determining what it would look like for the client to actively live those values on a daily basis. Here is where oftentimes a client will naturally not only describe what living their values might look like, but also how anxiety is preventing that. See below:

Client

“Yeah, definitely. Like I want to start a vegan activism group on campus or something. I don’t want to be like everyone else, but I still want close friends and to feel accepted.”

Therapist

“So if you were to live your values of friendship and tolerance, you might start by creating a club on campus that is welcoming to all. What else would it look like to live those values every day? Would you listen to music more too?” (The therapist can and should include interests and hobbies in addition to values). (Continued)

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(Continued) Client

“I would start an activism club, and I would definitely go to more concerts with friends. Or just hang out with friends more in general. That’s where my anxiety is getting in the way. I’m scared of putting myself out there and being judged or of going out to concerts and starting to feel panicky and not being able to escape. What if my friends don’t get it?”

Therapist

“So it sounds like this anxiety is really getting in the way of your life and of you living according to your values. That sounds pretty hard. But one thing that’s important to know about values is that they’re like cardinal directions—North, South, East, West. You can take steps toward them, but you’ll never arrive due North. We are all always just taking steps toward our values, and sometimes we get knocked off course by things like anxiety, but we can get back on track.”

At this point, the therapist has obtained a lot of rich data not only regarding what the client wants his or her life to look like, but also why it does not yet look that way. This is the beginning of a menu of ERP options that is not only based on the client’s fears and anxieties, but also on functionally preparing the client to live according to his/her values, an intrinsically motivating goal for many clients. At the end of the script, notice how the therapist also normalizes the experience of not living one’s values due to anxiety and provides hope, while distinguishing discrete and achievable goals from the values underlying them. Please see sample ERP menu at the end of this chapter for ideas regarding how to structure one. Cognitive defusion

Cognitive defusion is particularly helpful to discuss in the early phase of treatment as it will be referred to frequently during the exposure tasks. A tweak on the common lemon exercise is an especially effective method of demonstrating the power of thoughts to children and adolescents. In the lemon exercise, the therapist encourages the client to sit comfortably with eyes closed and to imagine holding a lemon. To increase present moment awareness, consider slowing down, and providing a detailed description of the lemon including as many sensory experiences as possible (e.g., notice the color of the lemon, the pores on its skin, the feel of its cool waxy weight in your hand, the fresh scent when the lemon is gently squeezed). Then, instruct the client to imagine cutting the lemon open and the associated sensory experiences. Finally, the client should imagine licking or biting into the lemon while the therapist narrates how it might taste, smell, and look. By this point, most clients report that they notice their mouth watered or puckered

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during the exercise, which the therapist can point out is a physical reaction our bodies create in response to thoughts about a lemon; however, there are no lemons in the room. In this way, we demonstrate to our clients that thoughts are powerful and can induce physical and emotional responses that we can regard as interesting mental phenomena without being necessarily factual. This is a first step in noticing thoughts as merely thoughts rather than mandates to act in a prescribed manner. Of note, this exercise is particularly suited to youth who identify their anxiety primarily in psychosomatic ways (e.g., our anxious feelings and thoughts can induce nausea, feeling faint or dizzy, and so forth, just as the thoughts of the lemon caused our mouths to water). Tip: There are many ways of talking about cognitive defusion with youth, the lemon example being just one. To maximize effectiveness, look for thoughts during a session that are serving functionally as barriers to forward progress and target them when discussing defusion. For example, a client may exhibit fusion with a particular thought such as “If I go out with friends, I will panic.” That thought is functionally preventing the client from the experiential aspect of the exposure and the possibility of an expectancy violation in which he or she does not panic. As a first step, labeling for the client that thought fusion is occurring often allows the client to think more objectively about the thought (metacognition), which allows for some amount of defusion (e.g., “is that thought helpful to you in reaching your goals, or is it keeping you stuck not going out and doing what you’d like?” or “there goes your brain, telling you the story it likes to tell you about what you can and can’t do.”) Defusing from thoughts may be a gateway to “bossing back” one’s anxiety as well. Acceptance

A third aspect of ACT that can be helpful to discuss during the early phase of treatment is acceptance, which is a concept closely related to willingness. Paradoxically, learning to accept our internal experiences rather than to fight them can “take the wind out of their sails.” For example, imagine that you are being chased by a lion. The faster you run, the more you activate the lion’s prey drive. You begin to tire from running at top speed and worry that you might be slowing down just enough for the lion to catch you. But wait! There is another way. If you stop and face the lion and perhaps yell at it “HERE I AM!” while waving your arms, the lion will likely stop chasing, surprised, and maybe even take a step back. This example is akin to how our anxiety or fear reacts when we stop avoiding or running from it. We must be willing to face the big scary lion (our anxiety) and accept it in order to fully participate in exposures and gain maximal value from them. During exposure tasks, therapists may frequently ask that the client “lean into” a negative experience, or deepen the anxiety associated with the exposure. To do this requires an

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implicit acceptance of the negative experience and a willingness to allow it to show up despite the discomfort associated with it. The goal in ACT informed ERP is not to eliminate or decrease the distressing thoughts, feelings, or experiences, although that may happen, but rather to learn that we can make room for the distress and be curious about it while continuing to pursue what is most important to us in life despite unpleasant feelings. Put in the language of inhibitory learning, the paralysis that often accompanies distress is a choice, and we can learn to make different choices or to behave flexibly in the midst of discomfort. For both parents and children, introducing the concept of acceptance early also sets the stage for realistic treatment expectations. Anxiety is based in an evolutionary fear response that includes a cascade of hormonal and physical reactions involving the hypothalamic pituitary adrenal (HPA) axis functioning and the sympathetic and parasympathetic nervous system, which control cortisol production, digestion, and pupil dilation among myriad other responses that aide us in quickly responding to a threat in our environment. This evolutionary fight or flight response is an adaptive mechanism; therefore, eliminating the experience of anxiety is not a realistic goal as our emotions are inextricably linked with our biology, although many clients will come to us with that hope. A nice metaphor for children and adolescents that illustrates that anxiety is part of our life and our biology is the weather metaphor, which may look something like this:

Therapist

“Our anxiety and emotional experiences are a little bit like the weather. We aren’t so good at controlling if it’s hot or cold or raining or snowing outside on any given day, but we are generally pretty good at putting on a shorts or a coat or rain boots. So, in treatment, I can’t change the weather, just like I can’t take away your negative emotions or anxieties, but we can together change our relationship to them by putting on a coat, or learning to manage whatever comes up on any particular day. What I want to caution is that sometimes it’s really easy to get in a struggle with the weather, like “I wish it weren’t cold AGAIN today!” but what does that do for us? Not much! Probably just makes us feel badly about another cold day. So let’s work together to notice when we are getting in a struggle with our emotions and trying to control or escape them, and maybe instead we can think about changing our relationship to them when that happens so we can keep on living the lives we want.”

Tip: Acceptance is one of the hardest concepts for clients to grasp, often because they come to therapy hoping we as therapists will “fix” or remove anxiety/discomfort. To hear us say “perhaps this is an area we don’t need to change or fix, but can instead work toward accepting

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and letting those feeling be there” is often disheartening for clients who may feel helpless and hopeless as a result. Be prepared for this reaction, and be ready to discuss how control strategies often backfire, leading to more of the distressing feelings. This work may look like a creative hopelessness intervention. One possible way of navigating this reaction is saying something like this: “We know what your life looks like when we try to control or get rid of your anxiety, we know where that path leads: (insert examples from client’s life here such as staying in bed all day when the scary feelings come up, or losing friendships, feeling bad about self, etc.). But we don’t know what life might look like for you if we stop trying to control how you feel all the time and let it just be there and move forward anyway. I know it may seem strange to welcome in hard feelings instead of trying to make them go away, but can you be curious with me about where this new approach might lead? What might it be like to have all those bad feelings and to take a step toward something you care about today?”

Identifying productive exposure tasks See page 23 for a sample exposure menu. As in traditional ERP, the client and the therapist collaboratively formulate a treatment plan and choose the exposures. In ACT-informed ERP, the tasks chosen are ideally consistent with the client’s goals and values (see script and section on values mentioned previously). Exposures are chosen based not only on what is challenging or anxiety provoking, but also on what is important to the client functionally. Choosing tasks carefully to match the client’s stated values is more likely to be naturally reinforcing, which maintains willingness. Importantly, while performing the exposure task, the therapist should continually bring back the focus to the client’s larger goal. If a child diagnosed with OCD reports a fear of becoming ill due to touching items in the bathroom or associated with it (toilet, wash cloths, sink, toothpaste, and other items traditionally kept in a bathroom), the value may be wanting to be able to go to friends’ homes to play, and if needed, to use their bathrooms without feeling forced to return home to participate in lengthy washing rituals. When formulating the exposure plan, the therapist in this example can capitalize on the child’s values of socializing, having and keeping close friends, and not disrupting play time. A value for a teenager may be the desire to use makeup and a hairdryer in the bathroom when preparing for a date without having to engage in cleaning or washing rituals due to touching “contaminated” bathroom items. While the exposure tasks themselves may be very similar or the same as in traditional ERP therapy, the focus should remain

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on the purpose of the exposure: the client’s stated values and the functional impairment caused by the anxiety. A second way in which ACT treatment for anxiety diverges from a strict ERP approach is in the idea of targeting self-concept via exposures when the self-concept is related to the client’s core fear. When discussing with colleagues, we often think of this as defining a client’s “inner okayness.” This is especially relevant for children and adolescents who are developmentally busy exploring the idea of who they are relative to others. Youth and parents often present with a fear that there is something inherently wrong with them or their child that warrants constant vigilance. In youth with obsessional fears of harming others or of engaging in sexually deviant behaviors, the self-concept can be maladaptive or a source of intense concern. For example, in the case of a young man who sought treatment for OCD because he experienced recurring intrusive violent and detailed images of harming others and of engaging in pedophilia, his self-concept was formulated in connection to his OCD, and he worried he was “at core a bad person.” In cases such as this, exposures related to what it might mean to “be a bad person” including writing scripts about going to prison, committing the feared crimes, and lacking a moral compass may more effectively target his self-concept opposed to more traditional harm exposures (e.g., holding a knife next to a loved one). Coaches and therapists can be instructed to give feedback regarding the harm scripts such as “You must be a monster to be able to imagine actually hurting someone else like this,” which targets the self-concept in addition to the actual harm thoughts by forcing the client to attend to his core fear that something is deeply wrong with him. ERP tasks can be created explicitly to target an adolescent’s maladaptive self-concept, but it can also be implicitly targeted through a simple line of questioning from the therapist such as “what might it mean to not be a hard worker all the time?” or “how would your life change if you weren’t able to be perfect in school?” At times, these simple thought experiments couched as conversations can function much like exposures. Pushing on rigid or tightly held ideas of the self can be a powerful tool for young people to imagine a life in which their symptoms are a part of them but do not define them. The larger goal in including selfconcept in exposures is formulating an idea of the self that encourages increased functioning and committed actions toward goals.

Integrating the family system into treatment The family system is important to consider when treating youth with anxiety disorders. Often, maladaptive patterns of family functioning are present that may maintain the anxiety in the client or undermine treatment goals. Outlining for parents what treatment looks like and how

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they can be involved is an essential first step (e.g., no longer rescuing the child from his or her anxiety, noticing that anxiety itself is not dangerous, etc.); however, the therapist benefits also from an understanding of the role of parenting in child development and may keep this framework in mind when evaluating a family system.

A brief primer on parenting styles Parental psychopathology is predictive of and predicted by child symptoms of psychopathology (Allmann, Kopala-Sibley, & Klein, 2015). As such, in any treatment of children, a basic understanding of the function of parenting behaviors and parental psychopathology as it relates to parenting practices in maintaining pathology is relevant. It should also be emphasized that child psychopathology maintains maladaptive parenting styles (Allmann, Kopala-Sibley, Klein, in preparation), suggesting that treating both parents and children simultaneously may be most beneficial. Baumrind’s (1967, 1971) classic conceptualization of parenting identified three parenting subtypes: authoritative, authoritarian, and permissive behaviors. Authoritative parenting is characterized by high warmth and appropriate amounts of control. Authoritative parents are emotionally supportive but also engage in appropriate limit setting, the use of reasoning, and are consistent in their expectations and rules. Authoritarian parenting includes high control but low warmth. Authoritarian parents maintain high expectations of their children, but are less emotionally supportive or nurturing. Permissive parenting, by contrast, is characterized by high warmth and low control. Permissive parents are emotionally supportive but fail to establish age- and developmentally appropriate boundaries or consistently follow routines. These three parenting styles, or similar constructs, emerge fairly consistently in factor analytic studies (e.g., Lee, Daniels, & Kissinger, 2006; Robinson, Mandleco, Olsen, & Hart, 1995; Robinson, Mandleco, Olsen, & Hart, 2001; Schaefer, 1965; Schludermann & Schludermann, 1970). Although these broad dimensions can be broken down into more specific parenting practices, such as hostility, rejection, warmth, control, structure, and coercion (see Sessa, Avenevoli, Steinberg, & Morris, 2001; Skinner, Johnson, & Snyder, 2005; Wilson & Durbin, 2012a, 2012b), the three broad parenting styles identified by Baumrind (Robinson et al., 1995, 1996) are most frequently included in the parenting literature. In addition, Parker has also found support for an overprotective parenting dimension (Parker, Tupling, & Brown, 1979), which is often studied in the context of anxiety and depressive disorders. Overprotective parents restrict their child’s autonomy via physical or psychological control,

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encourage excessive dependence on the parent, and communicate to the child through their overprotective behavior that the world is a dangerous place. Many studies have reported associations between overprotective parenting and anxiety disorders in youth (Rapee, 1997; Wood et al., 2003), although Gere et al. (2012) suggest that overprotective parenting may also relate to child behavior problems. When evaluating the family system, special attention should be paid to the parenting styles employed as the various styles are associated in the literature with certain outcomes and can yield important information about the function of the child’s behaviors in the family context. For example, authoritative parenting generally relates to positive psychological well-being (Larzelere, Morris, & Harrist, 2013; Baumrind, 1968), and as discussed previously, overprotective parenting is associated with anxiety disorders in youth. As therapists, we can provide psychoeducation to the family regarding appropriate parenting behaviors and the roles of authoritative, authoritarian, permissive, and overprotective parenting styles in maintaining psychopathology. Recent work also suggests that how we frame youngsters’ perceptions of their OCD is important in treatment outcome (Butlin & Wilson, 2018). In addition, how parents view their children’s OCD is also an important predictor of outcome, and is likely also related to their parenting style and mental health. A number of studies to date demonstrate that parents’ perceptions are related to the intensity of the child’s symptoms and treatment outcome (inability to tolerate child distress; Selles et al., 2017). Many of the same processes that are important in treating the child or adolescent will also be relevant when working with the family system. Teaching teenagers and parents to respond to adolescent anxiety flexibly rather than automatically is one of the initial treatment goals we formulate when working with families from an ACT informed ERP framework. Primarily, we aim to scaffold curiosity in parents of their child’s experiences and are careful not to model avoidance or rescuing behaviors with parents. Just as in their children, when anxiety and discomfort show up in parents, they may also over rely on avoidance strategies. It is worth noting that accommodation behaviors generally lead to reductions in child anxiety in the short run while also resulting in reductions of parent anxiety and discomfort. Watching someone who you care about deeply struggle is unpleasant, and many parents instinctively want to “fix” the problem quickly. Unfortunately, this knee-jerk “overprotective” reaction in many parents to protect their children from emotional pain often serves to maintain the anxiety in the long term. Parents may also experience shame at not being able to fix or “effectively parent,” which can lead to catastrophic thinking about what anxiety will do to their child, what others will think of them as parents, fear

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that their child will be damaged, or that anxiety will derail them from ever experiencing good relationships or a good/successful/productive/ happy life. These thoughts can seem very powerful and true, and can also sabotage parents’ ability to effectively manage their adolescent’s anxiety. Tip: Incorporate parents into treatment by allowing them to observe an ERP session without commenting at first. Model for them appropriate approach behaviors and language around anxiety. Next, debrief with parents and allow them the opportunity to ask any questions. At future sessions, invite parents to take the lead in the exposure, while you observe and provide feedback. This scaffolding model for parents is an experiential way to include them in their child’s treatment and provide them confidence that they can duplicate at home what they witnessed in your office.

Troubleshooting Once the exposure tasks are formulated, the therapist can begin the work of ERP treatment; however, it is a rare case that will go exactly as planned. Novel approaches to treatment often require some troubleshooting and a willingness on the part of the therapist to be creative and experimental in approaching challenges. When utilizing ERP, an example we frequently see is the moment when a teenager, faced with imminent ERP, has the thought, “I can’t. It’s too hard.” An ACT clinician, rather than engaging in a tug-of-war battle to get the child to do the ERP, may encourage them to notice the thought as a thought rather than a literal truth (feelings are not facts after all), notice what shows up inside when they have the thought or feeling, and mindfully choose whether to engage in ERP with an awareness of previous behavioral patterns when faced with the same or similar situations (e.g., “is this a familiar feeling? Have you been here before? And what happened when that thought came up in the past?”). ACT allows individuals to defuse from powerful thoughts and feelings and to experience them as simply thoughts that come and go and do not need to function as rules that direct behavior. In that same vein, many ERP therapists struggle to talk to their young clients about how to manage high levels of anxiety that can arise during exposures. Therapists may also experience discomfort bearing witness to their client’s distress without offering an alternative coping mechanism or reassurance. One way to frame higher levels of anxiety for the therapist and the client alike is to recognize it as a more powerful opportunity for learning. Likewise, variety in the intensity of ERP tasks can also be framed as desirable. The therapist can remind the

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client that life does not follow a set hierarchy; therefore, attempting exposures that span a range of difficulty levels may be beneficial in generalizing to life outside of treatment. Another strategy that is helpful when faced with challenges is to use deictic framing, or framing that involves one’s view of the self. Deictic framing promotes “time travel,” or the client’s ability to think about what a future or past version of themselves would advice to the current version of themselves. Often, this motivates bravery-based behaviors instead of avoidance-based behaviors. In a situation where an adolescent boy is stuck and refusing ERP, an ACT informed ERP therapist might ask the client to consider what he will think of himself an hour after successfully completing the exposure, or what he might think of himself an hour after refusing treatment. In this way, the client is able to mentally propel himself through the challenging exposure and to the other side, where he can evaluate his performance and connect with his inherent motivations for seeking treatment. Alternatively, a therapist can ask “what would future you tell present you? Is there any advice you would want yourself to know going into this exposure?” The idea is the same—encouraging the client to change his or her perspective on a situation and thereby granting him or her a degree of cognitive flexibility in approaching the ERP task. With treatment refractory OCD or anxiety disorders, ERP therapists may hear “this won’t work because it’s part of treatment, and it’s not real.” In these cases, an ACT clinician can utilize several strategies, two of which are addressed here. The first is to accept what the client is saying and validate the concerns while also pointing out that in some cases, the goal is not to become more anxious during exposures, but rather to become more curious and willing to explore what emotions do arise. By simply shifting the goal away from increased anxiety, often clients are able to engage more fully in the treatment, and paradoxically, increase their anxiety. The second strategy is to utilize “surprise” ERPs or to gently weave exposures into general conversation with the client so they feel less staged or forced. For example, with a teenager who struggles with perfectionism in school, the therapist may ask her to complete a pop quiz exposure in which the therapist times and grades her performance on a quiz for which she was not permitted to study. The client presumes the exposure is the pop quiz and getting critical feedback from the therapist about her performance on the quiz; however, at the end, the therapist can comment on the girl’s ERP performance and her unwillingness to stop trying to get good grades during exposures. These surprise ERPs can be more effective than the planned ones as they feel more “real” and target the core fear of performing imperfectly whether at school or in treatment. These exposures require creativity and a willingness on the part of the clinician to think outside the box as

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well as the client to trust the clinician and be open to whatever experiences may arise in treatment as in life. Finally, just as in traditional ERP, when utilizing ACT informed ERP, do continue to vary the context of the exposures to optimize treatment outcomes. Consider varying the time of day, the location, or even the child’s mood as a means of generalizing the learning across contexts. Only engaging in exposures every week at 4:00 p.m. in your same office is not going to generalize to outside life as readily as exposures done outside the office, with different coaches if possible, in the home, in restaurants, in the car, or wherever/ whenever the anxiety is most challenging for the client. Try the same exposure when the child is in different mood states to model that even on hard days or when we are not feeling well, we can still do difficult things. As you probably know, treatment gains are not linear, so varying the exposure difficulty and the setting or context is a very powerful tool to enhance learning.

Conclusions ACT helps anxious individuals specifically by fostering exploration of and curiosity about, rather than avoidance of, their experiences through teaching mindfulness and acceptance strategies. Specifically, mindfulness used in the context of exposure supports the development of broad and flexible attention to one’s psychological experiences. Consider that when individuals feel anxiety, they experience physiological arousal, and narrow their attention to threat cues only, to facilitate avoidance or escape. Even in the absence of specific anxiety cues, they might become hypervigilant for these, becoming preoccupied with avoiding any situations that could possibly elicit unwanted experiences (e.g., see anxiety sensitivity literature, Blakely, Abramowitz, Reuman, Leonard, & Riemann, 2017; Raines, Oglesby, Capron, & Schmidt, 2014; Schleider, Lebowitz, & Silverman, 2018). This narrow focus on anxiety results in less sensitivity to other cues in their environment, limiting their ability to learn from those cues. In essence, anxious avoidance is a closed system: individuals simply notice whether they are anxious, or not anxious, or how anxious. Their behaviors are shaped by this—they engage in what “works;” in other words, whatever actions lead to reduced anxiety, to the exclusion of noticing or attending to other cues either in the environment or internally, which fails to support inhibitory learning. This attempt to control anxiety, through focusing one’s attention to it and it alone, entraps individuals. Teaching mindfulness skills; specifically, present moment awareness, acceptance, and defusion during exposure to anxiety provides individuals with replacement behaviors

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and restructured cognitions: curiosity and exploration of interoceptive cues, as well as of the external environment, and treating unwanted experiences not as threats, but as opportunities to explore and to learn. This is not only consistent with traditional exposure-based approaches but also offers a sophisticated way of shaping purposeful attention towards anxiety and anxiety cues. You can think of it as a replacement behavior for distraction, cognitive rituals, and/or “white knuckling” during exposure. It also supports the development of inhibitory learning by reallocating one’s attention more broadly and flexibly (e.g., from anxious/non-anxious to the myriad other available cues from which to learn). An ACT approach requires thinking about exposure differently than more traditional approaches. Rather than conceptualizing the main outcome of exposure as habituation, it seeks to develop flexibility in the presence of unwanted psychological experiences (e.g., anxiety, interoceptive cues, obsessive thoughts). The criterion with which to measure the effectiveness of these behaviors is whether, or to what degree, they move individuals toward pursuits they find meaningful and fulfilling in life, regardless of emotional state. In fostering this goal, ACT requires the acceptance—not simply tolerance or “white-knuckling”—of difficult psychological experiences such as anxiety. This approach is flexible and principles-based, and may support gains over time, as anxiety will very likely wax and wane at different points and in the context of different stressors. Because ACT is a contextual approach, it encourages individuals to approach their fears especially when avoidance costs them valued action. Thus, approaching challenges, especially when it matters most, becomes thoroughly woven into their lives, and as such, comes under the control of powerful, naturally occurring reinforcers. If individuals learn how to “approach” their fears, especially when the cost of avoidance is to lose engagement in activities that are important to them, they may be more likely to maintain treatment gains. Finally, ACT fosters willingness to experience and explore anxiety and OCD in two ways: first, by undermining the functional utility of control strategies (i.e., creative hopelessness); and second, by squarely framing an individual’s behavior in the context of what is most meaningful or valuable to them (i.e., valuing). Undermining control strategies such as avoidance involves helping teens and their parents to experience that while these may work in the short term, they paradoxically increase anxiety and discomfort in the long term. In addition, when teens are crippled by avoidance and anxiety, they may also begin to experience depressed mood and hopelessness about their situation. That hopelessness they feel may represent their active tracking of real contingencies: the more they avoid their anxiety, the worse it gets, and their lives become smaller and more impoverished. Despite their very hard

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work, avoidance ultimately is not workable. This intervention is called “creative hopelessness,” and is the birthplace of curiosity about whether there might be a different way to approach life and its challenges, and if so, what that might be. While undermining control strategies motivates teens to pause and reconsider their use, values discovery and articulation provide a powerful reinforcer for engagement in approach behaviors and curiosity. Valuing, in ACT, refers to the touching upon, again in an experiential way, what one cares deeply about and is meaningful in his or her life. It is framed as a possible, highly desired outcome that can inspire committed action towards that end. For example, you might frame a challenging exposure exercise as a small step towards this larger end. This serves to support engagement in challenging tasks, and sustained approach behaviors, regardless of rising or receding levels of anxiety or OCD symptoms. It may also enhance generalization over time. Exposure therapy is a well-established method of treating anxiety disorders in youth, and there is a growing body of evidence to suggest that ACT is also a useful adjunctive tool therapists can keep in their tool sheds to use independently or alongside ERP. You may even find that it changes the way you think about your own life, fears, and motivations. Sample Menu of ERP Options Background: Fictional client J.M. is a 12 year-old female referred for social anxiety. She is currently attending school, but feels isolated and has few friends. She sits alone at lunch, does not attend middle school socials, and is starting to refuse her extracurricular dance classes. She also refuses to raise her hand in class and will not give required presentations, which are impacting her grades and her participation points. Her core fear is that people will think she is stupid. Below follows a rudimentary sample menu of ERP options linked with J.M.’s stated values (being a good friend, being physically active/healthy, being studious/intelligent). Note that we prefer to call “hierarchies” menus as we believe it better reflects the inhibitory learning model rather than the habituation/desensitization model. Also note that the menu below looks very similar, if not identical to a classic ERP menu. The differences in the method are most noticeable during the treatment itself in how the therapist approaches and talks about anxiety and the feared stimulus, rather than in the structure of the menu or the tasks themselves. Value being targeted—studious/intelligent Raising hand in class at least once per day Raising hand to answer a question that’s easy Raising hand to answer a question that’s hard Raising hand to answer a question and intentionally getting it wrong

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Speak at least once as part of group presentation in History class Take the lead on giving a presentation for next group assignment Volunteer to stand up in class and collect assignments for the teacher Tell a friend you received a worse grade on an assignment than you actually did Value being targeted—friendship Sit with someone new at lunch Invite friend/s to your house once per week Accept invitations with others Prepare for school social Buy a dress (can go out with friends to pick one) Imaginal exposure in advance of school social—imagine being there, tripping, being laughed at, reaction, and so on Intentionally say something “stupid” to friends Going to the bathroom at school even if other girls are already in there Value being targeted—fitness/health Attend at least some portion of dance class once per week Audition for recital Make a mistake in dance class (tell a friend about it?) Ask someone else in the class for help with a difficult move Invite a friend from school to join your dance class Write a script about falling onstage during dance recital audition

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IV. Adaptations for complex presentations