Traditional Workshop 12 - To Habituate or Not Habituate: Applying Inhibitory Learning, Positive Affect, and Habituation Models of Exposure Therapy to Youth Anxiety and Related Disorders

Much evidence suggests that exposure is the key, active ingredient in cognitive-behavioral treatment for youth anxiety disorders, and the largest treatment gains often occur after exposure is introduced in treatment. Still, recent studies have found that, of providers who largely report using cognitive-behavioral therapy, only 19% to 33% use exposure therapy to treat adults and only 5% use exposure therapy for youth. Many practicing clinicians report hesitance to utilize exposure due to concerns about potential harms to the client. When clinicians do opt to incorporate exposure into their treatment plan, exposure is often delivered in a manner inconsistent with its theoretical foundation and evidence base. For example, clinicians may pair exposure with relaxation techniques, which may reduce the potency of the exposure, or reassure the client that the feared outcome will not occur, which may undermine expectancy violation and inhibitory learning. The goal of this workshop is to equip clinicians with a deeper understanding of three distinct yet complimentary theoretical models of exposure therapy—the habituation model, the inhibitory learning model, and recent positive affect approaches—and practical applications for the treatment of youth anxiety and related disorders. The workshop will begin with an overview of the evidence-base for exposure therapy and an introduction of the three models, followed by discussion of how these models can inform case conceptualization, exposure planning, decision-making during exposure, and selection and assessment of exposure-relevant outcomes (e.g., within- and between-session fear reduction, distress tolerance). The workshop will also demonstrate how all of these exposure therapy models can be delivered in an affirming and inclusive manner to ensure that all youth benefit from these powerful techniques. The bulk of this workshop will be spent on live exposure demonstrations of these differing approaches with significant audience participation and feedback, designed to increase exposure competency and confidence. The workshop will conclude with an open Q&A session focused primarily on identifying and troubleshooting barriers to exposure implementation in attendee’s own practice settings.

Recommended Reading 1
Peterman, J. S., Carper, M. M., & Kendall, P. C. (2019). Testing the habituation-based model of exposures for child and adolescent anxiety. Journal of Clinical Child and Adolescent Psychology : The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 48(SUP1), S34–S44. https://doi.org/10.1080/15374416.2016.1163707
brRecommended Reading 2: Benito, K. G., & Walther, M. (2015). Therapeutic process during exposure: Habituation model. Journal of Obsessive-Compulsive and Related Disorders, 6, 147–157. https://doi.org/10.1016/j.jocrd.2015.01.006

Recommended Reading 3: Pittig, A., Heinig, I., Goerigk, S., Richter, J., Hollandt, M., Lueken, U., Pauli, P., Deckert, J., Kircher, T., Straube, B., Neudeck, P., Koelkebeck, K., Dannlowski, U., Arolt, V., Fydrich, T., Fehm, L., Ströhle, A., Totzeck, C., Margraf, J., … Wittchen, H.-U. (2023). Change of Threat Expectancy as Mechanism of Exposure-Based Psychotherapy for Anxiety Disorders: Evidence From 8,484 Exposure Exercises of 605 Patients. Clinical Psychological Science, 11(2), 199–217. https://doi.org/10.1177/21677026221101379

Recommended Reading 4: McGuire, J. F., & Storch, E. A. (2019). An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents. Cognitive and Behavioral Practice, 26(1), 214–224. https://doi.org/10.1016/j.cbpra.2017.12.003

Recommended Reading 5: Zbozinek, T. D., & Craske, M. G. (2017). The Role of Positive Affect in Enhancing Extinction Learning and Exposure Therapy for Anxiety Disorders. Journal of Experimental Psychopathology, 8(1), 13–39. https://doi.org/10.5127/jep.052615

Outline:
1. Introduction
a. Review of current evidence base for exposure
b. Review of cases/symptoms for which exposure is indicated in youth
c. Acknowledge cases/symptoms for which exposure is not indicated in youth
d. Discuss common misconceptions about exposure that limit its usage in routine care

2. Present 3 theoretical models of exposure
a. Habituation
b. Inhibitory learning
c. Positive affect

3. Discuss practical applications of theory to exposure-based treatment with children and adolescents
a. Theory-informed case conceptualization
b. Exposure planning, hierarchy building, and exposure selection
c. Clinical decision-making regarding therapist behaviors during exposure
d. Assessment of client distress during exposure
e. Assessment of client learning during exposure
f. Considerations for involving parents in exposure
g. Affirmative practices in the conduct of youth exposures
h. Determining when to conclude an exposure/when to conclude treatment

4. Clinical demonstration with audience members
a. Habituation
b. Inhibitory learning
c. Positive affect

5. Trouble-shooting real-life youth exposure challenges/Q&A