Augmentation Strategies
Additional strategies are often needed to augment Ex-CBT to fully address youth’s needs. Because traditional Ex-CBT was not originally developed to specifically address cultural and contextual factors, we provide basic guidance in this section for evidence-informed strategies that can supplement Ex-CBT to address cultural and contextual factors (which includes clinical complexities) - that can influence youth presentations in treatment. This list contains common strategies that arose from our practice-based, community-partnered research alongside an extensive literature review. This list is not exhaustive.
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We recommend that you utilize the Person-Centered Cultural Assessment Guide to determine your client’s individual needs, followed by the Case Conceptualization Guide to select the appropriate Ex-CBT and Augmentation Strategies for your client.
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Strategies are listed alphabetically. Each strategy includes a brief overview, followed by a notation describing which cultural and contextual factor(s) the strategy is intended to address. Then, brief information is provided about when and how the strategy might be used.
Note: The information contained in this section is intended to be an overview only, rather than a comprehensive guide to each strategy. However, whenever possible, we link to free external resources that have been developed by other scholars and practitioners for each of the strategies included.
Definition: This strategy entails initiating a conversation with the client to understand how specific sociopolitical events or sociopolitical climate more broadly may be impacting them and intentionally providing a space for the client to share their experiences.
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Cultural and Contextual Factor(s) addressed: Sociopolitical Context
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When to use: This strategy may be useful when societal or community level events (e.g., discriminatory laws or rhetoric, war, mass shootings, police shootings, community violence, protests) are directly or indirectly affecting clients. These events can lead to vicarious trauma and significant distress when not addressed; especially when they are related to aspects of a client’s identity. You can then support the client in dealing with their distress.
Note: For younger clients, it may be important to discuss these topics with caregivers first to determine how they discuss these topics within their family.
Definition: This strategy entails helping youth to recognize how behaviors influence their emotions and supporting youth to systematically engage in activities they may have withdrawn from and other meaningful or rewarding activities to help boost their mood. It can be a treatment on its own or alongside other treatment strategies like exposure.
Cultural and Contextual Factor(s) addressed: Client characteristics (comorbidities)
When to use: This strategy is most often recommended to be used when a client has low mood and lack of motivation. Behavioral Activation is the frontline psychosocial treatment for youth experiencing symptoms of depression, which is one of the most common comorbid conditions youth with anxiety and OCD can experience.
Client Advocacy and Empowerment
Definition: Advocacy entails helping the client feel empowered to take action for social change.
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Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports
When to use: This strategy may be useful for youth who have or are experiencing marginalization (interpersonally or socio-politically) based on their identity. Engaging in advocacy can help to empower youth to take values-consistent action, show them that their voice matters, boost their self-efficacy by communicating messages that are important to them, and connect with others with similar values.
Definition: This strategy entails supporting clients meet their basic needs and limit structural barriers to care.
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Cultural and Contextual Factor(s) addressed: Environmental Stressors
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When to use: This strategy should be used when basic needs are unmet, or when clients are facing structural barriers to care. Ideally, this is done before starting therapy to ensure that clients can fully benefit from therapy. In addition, as new stressors arise, clinicians may need to engage in advocacy to optimally support their clients (e.g., connecting to external resources for economic immigration-related stressors, communicating with the school to ensure equitable educational opportunities, support with access transportation). See the Relationship Building Strategies for examples of broader societal-level clinician advocacy.
Definition: This strategy is intended to help the client to identify and connect to personal (e.g., hobbies, skills, social identities), familial (e.g., family closeness) and cultural or community strengths (e.g., art/music, ancestral resilience, religious practices), which can foster positive development and a sense of belonging and empowerment.
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Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports, Environmental Stressors, Trauma
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When to use: This strategy may be used for any client but may be particularly useful for those who are experiencing identity-related or environmental stressors to build a sense of belonging, support positive identity development, and bolster social supports to cope with chronic stress. Engaging in joyful identity and values-consistent activities can be a form of resistance to identity-based discrimination. This strategy overlaps with racial-ethnic socialization when the focus is on exploring or engaging in racial/ethnic identity development. Importantly, all youth can benefit from highlighting their strengths to increase positive identity development.
Definition: This strategy entails teaching and providing clients and caregivers with resources to cope with racism and racial trauma
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Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports
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When to use: This strategy may be used when clients are experiencing racial stress or trauma, either acutely or chronically.
Definition: This strategy entails helping the client differentiate between true religious values and practices and OCD-driven religious obsession or compulsions or other anxiety about religion.
Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports
When to use: This is a helpful strategy for any client for whom religion is important. It is particularly critical when a youth’s religious beliefs become intertangled with their anxiety or OCD symptoms. A common place where this arises is for clients with scrupulosity, or a form of OCD that involves religious or moral obsessions or compulsions. Unlike typical religious practice, scrupulous behavior of beliefs usually exceeds religious law and is typically inconsistent with that of the rest of the faith community.
Definition: These strategies entail using techniques to support clients in being aware of their experiences in the present moment in order to create distance between the client and their distress.
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Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports, Environmental Stressors, Client Characteristics
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When to use: This strategy may be helpful for clients who are experiencing chronic stress related to their identities or environment, as well as those who have excessive worries or get stuck in worry thoughts, rumination, or obsessions. This strategy can help clients recognize, tolerate, and cope with constant worries and strong emotions by creating distance between themselves and their thoughts and experiences. Some strategies assist clients in creating distance by focusing on something else in their environment and some help clients see their experiences more objectively by observing them (e.g., what does the anxiety feel like in your body? Where does the sensation start? Where does it end? If you could draw a line around it, what would it look like?).
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Definition: This refers to a diverse set of strategies that includes a range of skills including, praise, one on one time, behavior charts, effective instructions, consequences, and more.
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Cultural and Contextual Factor(s) addressed: Client Characteristics
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When to use: These strategies can be utilized for any clients with a range of presenting problems. They are most often utilized for children who have externalizing behavioral challenges (i.e., have big emotions and express them outwardly). They can be utilized to help support positive relationship building between children and their parents and reduction of challenging behavior. Many of these strategies can also be used to support anxious children struggling with managing big feelings and to coach and reward them to engage in brave behavior.
*Note. It is important to consider what is leading to behavioral difficulties and ensure that you are also targeting any potential underlying challenges (e.g., experiences of trauma, chronic stressors).
Definition: Racial-ethnic socialization is the process by which clients can learn about and connect to their racial and ethnic background by developing and engaging in behaviors, perceptions, and values of that group.
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Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports (Racism specific), Social Identity-Related Stressors and Supports (Acculturation specific)
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When to use: This strategy may be used with youth experiencing racism, discrimination, or acculturation stress. Connecting youth to their racial/ethnic background and identity can facilitate development of a positive racial/ethnic identity, with the goal of positively influencing mental health.
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Definition: Relaxation entails intentional efforts to reduce the physiological responses associated with stress in the body. This can include using progressive muscle relaxation to reduce muscle tension and diaphragmatic breathing to reduce heart rate.
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Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports, Environmental Stressors
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When to use: This strategy may be helpful for clients experiencing high stress due to identity-related discrimination and those who experience high levels of chronic stress, or physiological arousal in response to anxiety. Relaxation strategies can help youth recognize that they can have some control over their physiological responses.
Note: For clients engaging in exposure therapy, relaxation is typically contraindicated directly before an exposure practice, as it can serve as a form of avoidance rather than tolerating the body sensations associated with anxiety and OCD. We encourage use of relaxation in three major ways: (1) to support coping with more chronic and realistic worries as they occur (e.g., during an acute stressful moment or experience), (2) to help youth who struggle to fall asleep at night due to chronic worry to help their brains “settle down” and relax enough to sleep, and (3) in service of “opposite action” principles (e.g., a youth who experiences an aggressive response when anxious or agitated might be coached to use relaxation to withdraw from a potentially aggressive encounter, rather than engage.
Definition: This strategy entails a systematic process for helping youth to identify potential solutions to the problems they are facing and then evaluate the pros and cons of each solution to select the best possible option. Problem-solving is a common component of CBT for youth with anxiety and OCD and can help to address a wide range of stressors that clients experience as a part of their daily lives.
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Cultural and Contextual Factor(s) addressed: All
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When to use: This strategy may be used when the client is experiencing distress from problems that are not easily addressed or when emotional decisions lead to negative consequences. Structured problem-solving can provide a structured framework to assist clients in making healthy decisions and ultimately give them confidence to handle problems that arise.
Definition: This strategy entails identifying spaces, people, or identity-based groups where clients feel comfortable expressing or discussing their identities.
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Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports
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When to use: This strategy may be helpful for clients who are experiencing discrimination based on their identities and/or have people in their life that are not accepting of their identities. Finding supportive people and places for clients to express their identity is important for their emotional safety and identity development.
Definition: Supporting physical safety entails determining risk and developing plans to help youth stay safe in their environmental context.
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Cultural and Contextual Factor(s) addressed: Social Determinants of Health, Social Identity-Related Stressors and Supports
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When to use: This strategy may be used when a client experiences environmental stressors (e.g., community violence, immigration-related stressors), or when a client with marginalized identities does not feel safe in a particular space given their identity. This often can be a crucial first step for youth to be able to engage in therapy if their environment is unstable at the start of treatment; however, youth may experience new-onset stressors over the course of treatment that may also warrant immediate attention.
Note: Rather than assuming what level of risk is appropriate, evaluate the level of risk that is acceptable to client/family.
Definition: Trauma processing involves developing a trauma narrative to help clients manage difficult memories and emotions and recognize maladaptive thinking related to the traumatic experience.
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Cultural and Contextual Factor(s) addressed: Environmental Stressors (Trauma), Stressors related to Social Identity
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When to use: This strategy may be used for clients who have experienced trauma. Experiences of trauma (included racial trauma) can co-occur with anxiety and OCD.
Definition: This strategy entails recognizing and accepting your client’s thoughts, feelings, sensations, and behaviors as understandable.
Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports, Environmental Stressors
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When to use: This strategy will be used with all clients, but is an especially important strategy for those youth who are experiencing identity-related or environmental stressors given the frequent invalidation they are likely to experience, especially by professionals. Validation is also and interpersonal effectiveness skill that is often taught in Dialectical Behavior Therapy.
Definition: This strategy entails assessing the client’s values to understand how they may affect their perceptions of therapy and inform goal identification for treatment.
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Cultural and Contextual Factor(s) addressed: Values, Beliefs, and Experiences of Mental Health
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When to use: This strategy may be useful when trying to understand what is important to a client/family to align treatment goals with their values or when they are hesitant to engage in exposures or other treatment strategies. Knowing a youth’s values can help support clinicians to encourage values-consistent behavior and explain how certain exercises (e.g., exposures) can fit their values and allow them to lead a lifestyle maximally consistent with the life that they want for themselves. It also can be helpful to understand potential conflicts between the treatment strategies and client values (e.g., if the caregiver values protecting their child, and that feels in conflict with helping their child engage in exposures) to inform future conversations and treatment planning.
Definition: This strategy entails general communication skills, such as empathetic listening and assertive communication, to help families address internal conflict.
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Cultural and Contextual Factor(s) addressed: Social Identity-Related Stressors and Supports
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When to use: This strategy can be useful for clients who are experiencing family conflict and may be particularly useful for immigrant or first-generation clients who come into conflict with parents because of differing values.
