Case Conceptualization
Clinical Guidance for Determining if a Fear Warrants Targeting with Ex-CBT
One of the most common challenges clinicians face (especially when working with marginalized youth) is determining when to target fears that may be realistic or helpful, and to what extent avoidance behaviors are adaptive.
There is no clear, universal rule of what fears and associated avoidance behaviors are and are not helpful; determining this can be challenging. Fear and avoidance are best understood as on a continuum, and understanding a client’s cultural and environmental context is essential for determining the extent to which a youth’s avoidance is adaptive or maladaptive. For example, physiological arousal and scanning your environment for danger can be adaptive or helpful in one setting (e.g., in a community with high levels of violence, walking an unfamiliar city street after dark) and less helpful in another (e.g., on a supervised school playground).
We recommend that clinicians work closely with clients and their caregivers to determine what avoidance behaviors are appropriate to target with Ex-CBT, guided by the child’s distress, level of impairment, family preferences and values, and clinical judgment. This is often challenging – a feared outcome (e.g. getting sick, becoming injured) may very well be possible; however, associated avoidance may be majorly interfering and still warrants treatment focus.
Culture can influence whether avoidance is considered adaptive or appropriate. For example, in many cultures a child sharing a bed with their caregiver may be normative and unnecessary to target, while in other families it may be disruptive.
Intergenerational anxiety also can influence whether avoidance is viewed as adaptive. For example, a parent who also struggles with anxiety may be more likely to view their child’s avoidance as non-problematic due to their own symptoms.
We also recommend that clinicians engage in ongoing self-reflection to increase awareness of their own perceptions of what is adaptive or maladaptive avoidance. You may ask yourself, “How do my own experiences inform my perspective of whether this avoidance is unhelpful?”, and “What realistic fears have I dealt with or not had to deal with that affect how I interpret my client’s fears?” Self-reflection can help avoid making assumptions and ensure treatment goals are set in collaboration with the client and their family and guided by what is most important to them.
An Avoidance Continuum document is provided with examples of how fears can lead to both adaptive and maladaptive avoidance across a continuum.
Case Examples Illustrating How to Determine if Ex-CBT is Appropriate
Case 1: An 8-year-old male who recently immigrated from Mexico is experiencing anxiety around leaving his mother and going out in public, including excessive reassurance seeking from his mother about whether she will be safe. Upon further assessment, it becomes clear that he is afraid of his mother being deported.
Case 2: A 13-year-old Black female presents with social and generalized anxiety worries, including fears of being harmed on public transportation or in her home, which leads to repeated lock checking and constant review of the news to see if there have been recent crimes in her area. It is unclear to what extent fear and avoidance should be attributed to environmental dangers or to unrealistic worry, intrusive thoughts, or compulsive behavior.
For both example cases, if the child endorses significant avoidance, even if their fear is realistic, some Ex-CBT practice is likely warranted. If the child is not experiencing significant maladaptive avoidance, exposure is likely not indicated and other supportive strategies should be used. If realistic fears are present, augmented strategies (e.g., supportive and advocacy strategies: See Augmentation Strategies Section) are likely warranted, regardless of whether Ex-CBT is also indicated.
*These case examples are based on client’s seen in a community clinic serving primarily low-income youth and families. It is important to note that aspects of culture and context should always be considered whether the client holds multiple or no marginalized identities.