While the prevailing evidence in the professional literature is that cognitive behavioral therapy is the gold standard in addressing problems like childhood anxiety disorders, the eminently reasonable principles of exposure and response prevention should be accompanied by what we know about emotional communication. That is, behavioral symptoms and the resistances to changing behaviors, even those that are not productive like compulsive actions or obsessive thinking, not only serve as the individual’s best attempt to cope, but also give us clues as to how to address them if only we take the time to decipher them.
For example, children who feel compelled to follow a ritual or have negative automatic thoughts that take a simple worry and transform them into huge fears, will be initially reluctant to give up these unproductive behaviors until they are convinced that they do not need them anymore. Meeting kids where they are-i.e. joining them-is the essential first step in rendering resistances to change no longer necessary. Here is an example in a case of selective mutism: the anxiety driving the resistance to not speaking must be respected by not pressuring the child to speak. Joining involves acting like the old sportscaster, Howard Cosell, and just broadcasting/describing what a child is doing with no questions asked. In this way, the child feels implicitly understood. The next step may be to ask forced choice questions that can be answered verbally by a yes or no or a nod of the head. In this way, we slowly scale the mountain of steps necessary to facilitate speaking. Joining or describing or mirroring are considered emotional communications-i.e. communications that help a child move progressively forward. Another important tool is object oriented talking. Here, we again take the focus off the ego (i.e. the child) by placing it elsewhere. This is an important emotional communication that can be powerful when applied correctly. For instance, if a child is not mastering an academic task at school, the emotionally responsive teacher may put the focus on herself/himself by asking about what he or she can do better to explain the work, assigning primary responsibility for the child’s lack of progress on the teacher.
The psychotherapy literature has long held that whatever approach is used, the relationship is the key. After all, why should anyone make themselves vulnerable by giving up a familiar albeit unproductive behavior if they do not feel that the person proposing such a change understands and listens to them? So when constructing a hierarchy of behavioral steps with the goal of extinguishing a behavior, it is important along the way to always be consulting with the child about the plan so it is a cooperative effort. I have found an important missing step is to inquire about how a proposed plan will fail before implementing it as this will yield important information before operationalizing a strategy. Making the child a partner, even if he or she is a reluctant partner, goes far in reaching the desired goals.