Anxiety is a normal, adaptive emotion that motivates us to prepare for future threats.
For some,
it occurs too frequently, more intensely than what is called for by the situation, and/or is present
in the absence of a real threat. When this occurs, it can impair many areas of functioning and
cause significant distress. As parents, it is natural to want to eliminate your child’s fear by
providing reassurance or allowing escape or avoidance. For the occasional fears, this is
perfectly acceptable; however, when an anxiety disorder is present, these responses actually
serve to maintain and increase anxiety in the long run.
Anxiety Maintenance Model
The model above illustrates how anxiety disorders are maintained through avoidance. For
example, when the boy with a dog phobia sees a dog, he has thoughts related to the
dangerousness of the dog (“It’s going to bite me”), which leads to fear. (Note that the anxious
thoughts lead to fear, not the situation itself.) The body’s natural response to fear is escape.
Once the boy successfully escapes the situation, he feels better. Therefore, his escape
response is reinforced, making it more likely that he will respond similarly in the future.
The problem is, if feared situations are always avoided, it prevents one from having the chance
to prove the anxious thoughts wrong, and worry continues.
Why not just teach the child to think differently? Well, I bet you can imagine how many times the
boy has been told that most dogs are pretty safe, and it does not help. One problem is that the
part of the brain responsible for fear is overriding the part of the brain responsible for
logic—when emotions are high, logic tends to go out the window. Another problem is the
strength of the belief in the anxious thoughts is too high. The most effective way to change
one’s thoughts is to change one’s experiences. Therefore, only through slowly facing the fear of
dogs, will the boy come to believe that dogs are safe and that he can handle anxiety-provoking
situations. This model holds true for all anxiety disorders—phobias, obsessive-compulsive
disorder, separation anxiety, social anxiety, post-traumatic stress disorder, and even more
general worries. This is why exposure therapy is the most effective treatment for anxiety
disorders.
What is Exposure Therapy?
Exposure therapy is a specific type of cognitive-behavioral therapy designed specifically for
treating anxiety disorders. It takes approximately 12–16 sessions and involves identifying
specific fears related to anxiety-provoking situations (e.g., overestimation of likelihood and
severity of the threat, fears that anxiety will be unmanageable and never ending), as well
techniques to challenge these fears, such as logical reasoning to evaluate the accuracy of
predictions (How often does this happen to me and others? How bad would it really be if my fear
came true?) and gradual exposure to a hierarchy of feared situations.
Fears are broken down to include several situations (about 10) that cause a range of fear levels.
For example, for a fear of dogs, the child may talk about dogs, draw or look at pictures of dogs,
view dogs in cages, sit in a room with a dog but not touch it, and pet various dogs deemed to be
safe by the owner (of course, we will never be 100% sure that a dog will not bite, just as we
cannot be certain that other feared outcomes will never happen, which is why it is important to
gauge the relative risk of having the anxiety disorder versus the risk of a negative outcome; we
never ask a child to do something that is dangerous).
The child must stay in the situation until the fear comes down on its own, without distractions or
other subtle avoidance behaviors. Over time, the anxiety will come down (this may take a while
at first). The exercise is repeated regularly until it no longer elicits fear, and then the child moves
to the next higher step. The child begins to gather evidence about the actual vs. predicted risk,
as well as the temporary nature of anxiety and his or her ability to manage it until it comes
down. Confidence grows as children move up their fear hierarchy, and by the time they reach
the most difficult exercises, they are fully prepared and usually do not fear them as intensely as
when they first created the hierarchy.
