Guidelines for Conducting
Culturally Responsive Exposure Practice
Goals:
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Help the client learn how to effectively cope with and tolerate anxious distress.
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Empower the client to approach anxiety provoking situations in a safe and values-consistent manner.
Exposure is intended to help youth face feared situations that lead to maladaptive avoidance driven by anxiety or fear of specific people, objects, or places, internal sensations that are not objectively dangerous and are causing substantial impairment and distress. Exposure should always be driven by assessment of culture and context to inform case conceptualization and ensure that exposure is not used inappropriately (e.g., does not encourage social exposure or habituation in an environment where one is at high-risk for experiencing discrimination).
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While the principles below that support a culturally responsive approach to exposure can be applied to any youth struggling with anxiety or OCD, they specifically focus on strategies for youth from marginalized and minoritized identities. For broader guidance on the application of exposure therapy principles to youth, please see www.bravepracticeforkids.com for free tip sheets on exposure delivery.
Guiding Principle #1
Exposure practices should be selected collaboratively and should align with youth goals and values. A key challenge in identifying appropriate exposure practices and the pace with which to approach them is youth or caregiver reluctance to put themselves in seemingly difficult or scary situations. Co-developing the fear hierarchy with youth and families, guided by youth and family values, is critical to exposure success.
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Intended Impact: Help the client engage in safety learning related to their maladaptive anxiety and move the client toward their goals, all without exposing the client to unnecessary harm. This is particularly important when working with youth experiencing cultural and environmental stressors, as exposing them to those stressors could cause emotional or physical harm
Guiding Principle #2
We are asking clients to engage in anxiety provoking activities. Even the most culturally responsive and respectful exposure practices may still result in hesitancy from the client or caregiver.
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Intended Impact: Use reflective and transparent processes to support engagement in values consistent exposures.
Guiding Principle #3
Most, if not all, exposure practices carry some natural inherent risk (as all life does). Have a plan for how you will support the client if some aspect of a feared outcome occurs. As much as we might hope otherwise, we can never guarantee a positive outcome of an exposure practice, especially practices that involve testing principles of uncertainty (as many exposures do!). When appropriate, we want to help clients learn that their feared outcome will not occur.
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Intended Impact: Help the client learn that they can tolerate their emotions and manage a situation that feels like a “bad outcome” to reach their goals, especially for clients whose feared outcomes have occurred in the past and may occur again (e.g., experiences of discrimination).
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Note. Importantly you would never put a client in a situation to intentionally have them experience or tolerate physical or emotional harm.
Exposure therapy is an extremely powerful tool that must be wielded with care and great precision. It is also only one tool and often benefits from being combined with other treatment strategies to optimally support youth.
Careful case conceptualization to identify when to use exposure and when to augment or sequence exposure with other treatment strategies is critical to successful treatment outcomes (see Case Conceptualization and Augmentation sections for additional guidance).
Example Exposure Hierarchies for Youth with Anxiety or OCD Related to Identity or Environmental Stressors
Example 2: Ari is a 13-year-old with OCD who identifies as a cisgender male and a Modern Orthodox Jew. He experiences distressing obsessions and associated compulsions related to fears of violating Jewish Kashrut law by mixing meat with dairy products. Ari engages in excessive handwashing and cleaning of surfaces, as well as repeated checking and reassurance seeking from parents to ensure that he has not accidentally violated religious dietary practices
Example 1: Jade is a 10-year-old child seeking treatment for social anxiety, who fears embarrassment, standing out as different, and rejection from peers and adults. She identifies as a Black cis-gender female. She lives in a predominantly affluent, White area and is one of only a handful of Black students in her school. Jade also reports a history of experiencing race-based microaggressions at school related to her appearance and school performance.
