One of the most common problems clients will bring to therapy is anxiety. Estimated to afflict as much as 33.7% of the population at some point in life, an anxiety disorder can be a debilitating issue to endure. 1
Cognitive behavioural therapy continues to be the standard approach for working with people with anxiety disorders. In this model, clients learn coping strategies like deep breathing and relaxation, problem-solving, and cognitive skills to help them identify the irrational nature of many worries, and replace those anxious thoughts with more helpful thoughts.
For many anxiety issues, there is an additional step: exposure. As the saying goes, “Face the thing you fear and you do away with that fear”.
Exposure works simply because most of the things we are terrified of experiencing, really are not all that dangerous.When we deliberately confront these situations, we discover that we are okay, that nothing terrible happened to us, and that we can handle our anxiety.
But getting a client to see the value of confronting their fears is another story. Anxiety is a protective emotion – it exists to alert us to the presence of danger, to prepare our bodies to react to threat, and to thereby keep us safe. So when faced with danger, our hearts pound, our hands sweat, our breathing accelerate, our muscles tighten, or even to freeze up. In doing so, our bodies help us to keep safe.
In a feared situation – and I don’t mean one where there is real danger – but rather, a situation where there is perceived danger, our body still reacts with the same physical fight, flight, or freeze reaction, and we will naturally run away from that situation. In fact, even the anticipation that our body will experience that anxiety response is enough to keep us away from feared situations. So we avoid the public speaking scenarios or getting on the airplane altogether, even though these things are perfectly safe.
Kids will react the same way to their anxieties: they may avoid the party, or the classroom, or staying over at a friends’ house. But avoidance, while keeping us physically safe, does a disservice to us in situations where we face anxiety but no real danger. Avoidance strengthens our body and brain’s anxiety response. Every time we avoid a situation and our anxiety goes away, we reinforce the need to avoid that situation in order to prevent ourselves form suffering anxiety. We can end up avoiding more and more situations to prevent the discomfort of anxiety, which can lead to a very limited life.
Only by exposing ourselves to the situations and letting the anxiety run its course can we break the cycle of avoidance that maintains and even strengthens the fear.
These exposure handouts are designed to help older kids and teens start to face their feared situations. The worksheets use metaphors of a tall tower and climbing a mountain to express the fact that there are different degrees of anxiety and that anxiety, no matter how insurmountable it seems, can be overcome one step or one floor at a time.
This resource should be used middle stage of counselling, after rapport has been built and after the child has had time to learn about anxiety. The child should understand how anxiety feels within the body and should have developed some coping strategies to help her be successful with exposure exercises. At this point the therapist can explain the process of the child gradually exposing herself to feared situations, starting with the easiest and progressing toward more difficult feared situations as she gets more confident.
The client and therapist can then fill in the blanks on the worksheets with the different feared situations that she wants to overcome. If it is one main fear, flying for example, the fear can be broken down into smaller steps. Perhaps the client can start with looking at pictures of planes or visiting an airplane museum. They may progress to standing on the balcony of a building. Then they may take a short helicopter ride before progressing to a longer flight in an airplane. For this exercise it is important to break down fears that cause a lot of anxiety. The worksheets rely on a systematic desensitization approach to overcoming anxiety, as opposed to a flooding approach, in which the client would face a large fear right away and might be overwhelmed by the anxiety response and flee from the feared situation. With a flooding approach, the client may end up inadvertently strengthening the fear response and the sense that the fear cannot be overcome.
Once the clinician and the child have come up with a list of situations, the therapist can explain some of the details of the exposure process to the child, teen, and parents.
Some considerations as you work towards doing exposure tasks with the child:
- Set the child up for success. Baby steps that are successful are better than taking a bigger step that does not work out. If the child with school anxiety can only be in the classroom for 1 minute, start with that and build from there. Don’t insist on the child going to school for the whole day or the teacher may end up calling the parent for the distraught child halfway through first period.
- Have the child rate her anxiety on a scale from 1-10, where 10 is the most anxiety she could possibly feel and 1 is very little. Have her rate her anxiety before starting the task, at the start of the task, and periodically throughout the task. The longer the child stays in the situation, the more the level of anxiety should drop.
- Have the child stay with the task until it is completed or until the anxiety level drops to the point where it is half as much as when starting. If she is at an 8 at the start of the exposure task, she should continue in the task until the anxiety drops to 4 or lower. Repeat that same exposure task until engaging in the activity no longer causes a high spike of anxiety.
- Use only what coping strategies are necessary while in each step of the process. As a general rule, I’m a big fan of giving clients all kinds of coping strategies for managing anxiety. But when it comes to exposure, we don’t want to give clients others ways of avoiding their fears. I generally will encourage clients to use deep breathing or body relaxation exercises if needed and will help them come up with some coping thoughts that they can use while doing the exercise. I don’t encourage strategies that have the clients visualize being somewhere else in their minds. These strategies are helpful for generalized anxiety, but in an exposure scenario can be another means of avoiding really facing the feared situation. That being said, depending on the severity of the anxiety, one client may need to use more coping strategies than someone else at different stages of the exposure process.
- Try to arrange for at least a couple of exposure tasks to be done in the session or with the therapist. This may not always be possible, but at least try to do a couple of tasks with the child that involve her visualizing the feared scenario. As she imagines facing a feared situation, have her go through the process of rating her anxiety, using strategies, and staying with the situation will give her practice and familiarity with the process to start to do some small tasks on her own.
- Involve the parents.
Exposure is an intense emotional process and the child will benefit from having the support and involvement of his or her caregivers.They should know what their child is working on in therapy, what the process looks like, and be able to encourage the child to do any tasks between sessions (homework tasks can be more easily remembered with the help of a parent). Furthermore, for school-aged children especially, some of the exposure exercises may actually require the involvement of the parents to set up or transport the child.
I hope you find these worksheets helpful as you work with your child and youth clients on overcoming their anxiety. You can download the Anxiety Mountain handout in PDF or JPG and the Anxiety Tower handout in PDF or JPG form.
Join the discussion: In the comments box, let us know what are your favourite worksheets for helping kids overcome anxiety?