What caregivers like the most (and least) about cognitive behavioral therapy for youth anxiety: A mixed methods approach.

Cognitive behavioral therapy (CBT) is an efficacious therapy for youth anxiety disorders. Caregivers are key stakeholders in youth therapy, and their feedback on treatment can help to inform intervention personalization. This mixed-methods study applied a systematic inductive thematic analysis to identify themes among most- and least-liked CBT features reported by caregivers using open-ended responses on the Client Satisfaction Questionnaire (CSQ-8). The sample included 139 caregivers of youth ages 7-17 (M = 12.21, SD = 3.05; 59% female; 79.1% Caucasian, 5.8% Black, 2.9% Asian, 2.2% Hispanic, 7.9% Multiracial, 2.2% Other) with principal anxiety diagnoses who completed 16-sessions of CBT. CSQ-8 quantitative satisfaction scores (M = 29.18, SD = 3.30; range: 16-32) and survey-based treatment response rates (responders n = 93, 67%) were high. Most-liked treatment features included: coping skills (i.e., exposure, understanding/identifying anxiety, rewards, homework), therapist factors (interpersonal style/skill, relationship, accessibility), caregiver involvement, one-on-one time with a therapist, structure, consistency, and personally tailored treatment. Least-liked treatment features included: questionnaires, logistical barriers, telehealth, need for more sessions, non-anxiety concerns not addressed, insufficient caregiver involvement, and aspects of exposure tasks. Proportional frequencies of most- and least-liked themes differed by treatment responder status (e.g., responders cited exposure and homework as most-liked more frequently).

Parent-identified barriers to accessing exposure therapy: A qualitative study using process mapping.

Background: Youth with anxiety and obsessive-compulsive disorder (OCD) rarely access exposure therapy, an evidence-based treatment. Known barriers include transportation, waitlists, and provider availability. Efforts to improve access to exposure require an understanding of the process that families take to find therapists, yet no prior studies have examined parents' perspectives of the steps involved. Methods: Parents of children who have received exposure therapy for anxiety and/or OCD (N = 23) were recruited from a hospital-based specialty anxiety clinic where the majority of their children previously received exposure. Recruitment was ongoing until thematic saturation was reached. Parents completed questionnaires and attended an online focus group during which they were asked to describe each step they took-from recognizing their child needed treatment to beginning exposure. A process map was created and shown in real-time, edited for clarity, and emailed to parents for member checking. Authors analyzed process maps to identify common themes. Results: Several themes emerged, as visually represented in a final process map. Participants identified a "search-outreach" loop, in which they repeated the cycle of looking for therapists, contacting them, and being unable to schedule an appointment due to factors such as cost, waitlists, and travel time. Parents often did not know about exposure and reported feeling guilty about their lack of knowledge and inability to find a suitable provider. Parents reported frustration that medical providers did not often know about exposure and sometimes dismissed parents' concerns. Participants emphasized the difficulty of navigating the mental health system; many reported that it took years to find an exposure therapist, and that the search was sometimes stalled due to fluctuating symptoms. Conclusion: A common thread among identified barriers was the amount of burden placed on parents to find treatment with limited support, and the resultant feelings of isolation and guilt. Findings point to several directions for future research, such as the development of parent support groups for navigating the mental health system; enhancing coordination of care between medical and mental health providers; and streamlining referral processes.

Exposure to exposure: A protocol for leveraging exposure principles during training to address therapist-level barriers to exposure implementation.

Background: Exposure therapy is a highly effective but underutilized treatment for anxiety disorders. A primary contributor to its underutilization is therapist-level negative beliefs about its safety and tolerability for patients. Given functional similarities between anxious beliefs among patients and negative beliefs among therapists, the present protocol describes how exposure principles can be leveraged during training to target and reduce therapist negative beliefs. Methods: The study will take place in two phases. First, is a case-series analysis to fine-tune training procedures that is already complete, and the second is an ongoing randomized trial that tests the novel exposure to exposure (E2E) training condition against a passive didactic approach. A precision implementation framework will be applied to evaluate the mechanism(s) by which training influences aspects of therapist delivery following training. Anticipated results: It is hypothesized that the E2E training condition will produce greater reductions in therapists' negative beliefs about exposure during training relative to the didactic condition, and that greater reduction in negative beliefs will be associated with higher quality exposure delivery as measured by coding of videotaped delivery with actual patients. Conclusion: Implementation challenges encountered to date are discussed along with recommendations for future training interventions. Considerations for expansion of the E2E training approach are also discussed within the context of parallel treatment and training processes that may be tested in future training trials.

Therapist perceptions of experiential training for exposure therapy.

BACKGROUND: Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use. AIMS: This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training. METHOD: Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use. RESULTS: Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures. DISCUSSION: Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.

Response Inhibition in Youth Undergoing Intensive Treatment for Obsessive Compulsive Disorder.

Response Inhibition (RI) is the ability to suppress behaviors that are inappropriate for a given context. Obsessive-compulsive disorder (OCD) has been associated with impaired RI in adults as measured by the Stop Signal Task (SST). Conflicting results have been found in terms of the relationship between OCD severity and SST performance, and no studies to date have examined the relationship between SST and response to OCD treatment. Also relatively unknown is whether RI performance in OCD is associated with developmental or gender differences. This naturalistic study examined the relationship between SST performance, OCD severity, and OCD treatment response in a pediatric sample undergoing intensive treatment involving exposure and response prevention and medication management (n = 36). The SST and Children's Yale-Brown Obsessive Compulsive Scale (CYBOCS) were administered at admission and program discharge. OCD severity was not significantly related to stop signal reaction time (SSRT) in the whole sample and among subgroups divided by age and gender. Baseline SSRT and SSRT change did not predict CYBOCS change across treatment in the whole sample, but exploratory analyses indicated both were significant predictors among female adolescents. Results suggest there may be developmental gender differences in the relationship between RI and clinical improvement in pediatric OCD.

The Pediatric Accommodation Scale: Psychometric Evaluation of a Therapist-Report Format.

Anxiety disorders are the most common mental health problem in youth, and accommodation is prevalent among youth with anxiety disorders. The Pediatric Accommodation Scale (PAS) is an interview administered by trained evaluators and a parent-report form (PAS-PR) to assess accommodation and its impact. Both have strong psychometric properties including internal consistency, inter-rater reliability, and data supporting construct validity. The present study evaluates the Pediatric Accommodation Scale - Therapist Report (PAS-TR), a therapist-reported version of the PAS-PR. Participants were 90 youth enrolled in cognitive behavioral therapy for anxiety. Therapists completed the PAS-TR over 16 therapy sessions. Internal consistency at baseline, convergent validity, divergent validity, and parent-therapist agreement were evaluated. Results suggest that the PAS-TR has mixed psychometric qualities suggesting that while not strong prior to the initiation of treatment, the PAS-TR may be a useful measure for therapists to rate accommodation as treatment progresses. Implications for assessment, treatment, and research are discussed.

Precision Implementation: An Approach to Mechanism Testing in Implementation Research.

Advancing mechanism-focused research in implementation science is a priority given its potential to improve tailoring and efficiency of implementation strategies. Experimental therapeutics, or experimental medicine, offers an approach for mechanism testing that has been promoted by the NIH Science of Behavior Change and endorsed by the National Institute for Mental Health. This approach has been applied across the translational spectrum - with initial applications to biological research and more recent applications to psychosocial treatment development research. We describe further advancement of experimental therapeutics along the translational spectrum and describe how it is ideally suited to inform precision experimental tests of implementation strategy mechanisms, which we term precision implementation. Such an approach to mechanism testing will allow for identification of causal dose-response relationships between implementation strategies, presumed mechanisms, and implementation outcomes. We discuss the tension between the scientific rigor required to conduct mechanism-focused research using experimental therapeutics and the "real world" conditions in which implementation research takes place. We provide a series of example studies that show "beginning to end" application of this framework in research focused on provider implementation of an evidence-based intervention in routine clinical care settings.

Expanding the reach of evidence-based mental health interventions to private practice: Qualitative assessment using a policy ecology framework.

Background: Evidence-based interventions (EBIs) for mental health disorders are underutilized in routine clinical practice. Exposure therapy for anxiety disorders is one particularly difficult-to-implement EBI that has robust empirical support. Previous research has examined EBI implementation determinants in publicly funded mental health settings, but few studies have examined EBI implementation determinants in private practice settings. Private practice clinicians likely face unique barriers to implementation, including setting-specific contextual barriers to EBI use. The policy ecology framework considers broad systemic determinants, including organizational, regulatory, social, and political contexts, which are likely relevant to EBI implementation in private practice settings but have not been examined in prior research. Methods: Qualitative interviews were conducted to assess private practice clinicians' perceptions of EBI implementation determinants using the policy ecology framework. Clinicians were asked about implementing mental health EBIs broadly and exposure therapy specifically. Mixed methods analyses compared responses from clinicians working in solo vs. group private practice and clinicians who reported high vs. low organizational support for exposure therapy. Results: Responses highlight several barriers and facilitators to EBI implementation in private practice. Examples include determinants related to organizational support (e.g., colleagues using EBIs), payer restrictions (e.g., lack of reimbursement for longer sessions), fiscal incentives (e.g., payment for attending training), and consumer demand for EBIs. There were notable differences in barriers faced by clinicians who work in group private practices compared to those working in solo practices. Solo private practice clinicians described ways in which their practice setting limits their degree of colleague support (e.g., for consultation or exposure therapy planning), while also allowing for flexibility (e.g., in their schedules and practice location) that may not be available to clinicians in group practice. Conclusions: Using the policy ecology framework provides a broad understanding of contextual factors that impact private practice clinicians' use of EBIs, including exposure therapy. Findings point to potential implementation strategies that may address barriers that are unique to clinicians working in private practice.

Improving Delivery Behaviors During Exposure for Pediatric OCD: A Multiple Baseline Training Trial With Community Therapists.

This study tested whether a new training tool, the Exposure Guide (EG), improved in-session therapist behaviors (i.e., indicators of quality) that have been associated with youth outcomes in prior clinical trials of exposure therapy. Six therapists at a community mental health agency (CMHA) provided exposure therapy for 8 youth with obsessive-compulsive disorder (OCD). Using a nonconcurrent multiple baseline design with random assignment to baseline lengths of 6 to 16 weeks, therapists received gold-standard exposure therapy training with weekly consultation (baseline phase) followed by addition of EG training and feedback (intervention phase). The primary outcome was therapist behavior during in-session exposures, observed weekly using a validated coding system. Therapist behavior was evaluated in relation to a priori benchmarks derived from clinical trials. Additional outcomes included training feasibility/acceptability, therapist response to case vignettes and beliefs about exposure, and independent evaluator-rated clinical outcomes. Three therapists reached behavior benchmarks only during the EG (intervention) phase. Two therapists met benchmarks during the baseline phase; one of these subsequently moved away from benchmarks but met them again after starting the EG phase. Across all therapists, the percentage of weeks meeting benchmarks was significantly higher during the EG phase (86.4%) vs. the baseline phase (53.2%). Youth participants experienced significant improvement in OCD symptoms and global illness severity from pre- to posttreatment. Results provide initial evidence that adding the EG to gold-standard training can change in-session therapist behaviors in a CMHA setting.

Therapist Behavior During Exposure Tasks Predicts Habituation and Clinical Outcome in Three Randomized Controlled Trials for Pediatric OCD.

This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and posttreatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach-and less use of accommodation, unrelated talk, and externalizing language-predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher "total dose" of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the "black box" of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.

Core Motivations of Childhood Obsessive-Compulsive Disorder: The Role of Harm Avoidance and Incompleteness.

In an effort to improve patient conceptualization and targeted treatment, researchers have sought to accurately classify OCD subtypes. To date, the most common form of OCD classification has used the content of symptom topography as opposed to functional links between symptoms to categorize OCD. The aim of the current study was to explore the associations between these two forms of OCD classification. Participant topographical symptoms were self-reported using the Obsessive-Compulsive Inventory-Child Version (OCI-CV). Clinicians assessed whether participant symptoms were motivated by harm avoidance and/or incompleteness. Structural equation modeling was employed to explore the associations between harm avoidance and incompleteness and symptom dimensions in youth with OCD. Results showed that harm avoidance was significantly associated with doubting/checking, obsessing, and neutralizing symptoms, whereas incompleteness was associated with doubting/checking, ordering, and neutralizing symptoms. Findings are consistent with child and adult literature and highlight the importance of assessing the underlying function of OC behaviors.

Moderators of Psychosocial Treatment for Pediatric Obsessive-Compulsive Disorder: Summary and Recommendations for Future Directions.

This brief report examines the evidence for moderators of psychosocial treatment for youth with obsessive-compulsive disorder (OCD). Understanding treatment moderators can help clinicians select the most appropriate intervention for a particular patient and consequently increase the likelihood of initial response. A systematic search of the literature was conducted to identify randomized trials and meta-analyses reporting on moderators of psychosocial treatment for pediatric OCD. All studies included a comparison of cognitive-behavioral therapy (CBT) to active or control conditions. Few studies have evaluated moderators of psychosocial treatment for youth with OCD, and among those studies, few variables have demonstrated a differential effect on treatment response. Moderator analyses require large samples to garner the statistical power necessary to adequately evaluate differential responding in subgroups, and unfortunately, most reports of moderators in this review are post-hoc investigations of datasets from trials with relatively small sample sizes. Given the overwhelming number of CBT treatment variants and potential moderators, it would be impossible to conduct all the necessary head-to-head trials with sufficient sample sizes to develop helpful clinical guidelines. The best option for advancing the moderator literature is to utilize advanced statistical approaches for pooling existing data sets. Recommendations for leveraging emerging techniques in individual participant data meta-analysis (IPD-MA) are briefly discussed.

A Neurocognitive Comparison of Pediatric Obsessive-Compulsive Disorder and Trichotillomania (Hair Pulling Disorder).

Obsessive-compulsive disorder (OCD) and trichotillomania (hair pulling disorder, HPD) are both considered obsessive-compulsive and related disorders due to some indications of shared etiological and phenomenological characteristics. However, a lack of direct comparisons between these disorders, especially in pediatric samples, limits our understanding of divergent versus convergent characteristics. This study compared neurocognitive functioning between children diagnosed with OCD and HPD. In total, 21 children diagnosed with HPD, 40 diagnosed with OCD, and 29 healthy controls (HCs), along with their parents, completed self-/parent-report measures and a neurocognitive assessment battery, which included tasks of inhibitory control, sustained attention, planning, working memory, visual memory, and cognitive flexibility. A series of analyses of variance (or covariance) indicated significant differences between groups on tasks examining planning and sustained attention. Specifically, children in both the OCD and HPD groups outperformed HCs on a task of planning. Further, children with OCD underperformed as compared to both the HPD and HC groups on a task of sustained attention. No between group differences were found with respect to tasks of reversal learning, working memory, spatial working memory, visual memory, or inhibitory control. The implications these findings may have for future, transdiagnostic work, as well as limitations and future directions are discussed.

Pediatric OCD in the era of RDoC.

The NIMH Research Domain Criteria (RDoC) initiative was established with the goal of developing an alternative research classification to further research efforts in mental health. While RDoC acknowledges that constructs should be considered within a developmental framework, developmental considerations have not yet been well integrated within the existing RDoC matrix. In this paper, we consider RDoC in relation to pediatric OCD, a paradigmatic example of a neuropsychiatric disorder that often has onset in childhood but is also present across the lifespan. We discuss three RDoC subdomains with relevance to OCD as exemplars, providing for each construct a brief review of normative developmental changes, the state of construct-relevant research in pediatric OCD, and challenges and limitations related to developmental considerations within each subdomain. Finally, we conclude with a brief discussion of how RDoC may continue to evolve with regard to developmental considerations in order to further research in pediatric OCD.

Evidence Base Update of Psychosocial Treatments for Pediatric Obsessive-Compulsive Disorder: Evaluating, Improving, and Transporting What Works.

Pediatric obsessive-compulsive disorder is a chronic and impairing condition that often persists into adulthood. This review refreshes the state of support for psychosocial treatments and the predictors or moderators that relate to their efficacy and evaluates how the literature has improved since the last update in 2014. A secondary goal is to propose an additional framework for the categorization of studies based on central research questions rather than treatment format. Psychosocial treatment studies conducted since the last review are described and evaluated according to methodological rigor and evidence-based classification using the Journal of Clinical Child and Adolescent Psychology evidence-based treatment evaluation criteria. Findings again converge in support of cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with obsessive-compulsive disorder. Family-focused CBT is now well-established. A number of other treatments including CBT+ D-Cycloserine, CBT+ Sertraline, CBT+ positive family interaction therapy, and technology-based CBT are now probably efficacious. Demographic, clinical, and family factors are consistent predictors of CBT outcome with conflicting findings for neurocognitive predictors. The field has advanced significantly since the last review, but there is still room for improvement. Some of the conclusions that can be drawn may be limited by our evaluation criteria. Future directions are proposed to advance treatment outcome research beyond a focus on which treatments work to exploring factors that account for how and why they work.

Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD.

OBJECTIVE: This study measured a variety of within-exposure fear changes and tested the relationship of each with treatment outcomes in exposure therapy. METHOD: We coded 459 videotaped exposure tasks from 111 participants in 3 clinical trials for pediatric obsessive-compulsive disorder (OCD; POTS trials). Within exposures, fear level was observed continuously and alongside exposure process. Fear change metrics of interest were selected for relevance to mechanistic theory. Fear decreases were classified by function; nonhabituation decreases were associated with observed nonlearning processes (e.g., avoidance), whereas habituation decreases appeared to result from an internal and indirect process. Outcomes were posttreatment change in symptom severity, global improvement, and treatment response. RESULTS: Greater cumulative habituation across treatment was associated with larger reductions in symptom severity, greater global improvement, and increased odds of treatment response. Fear activation, fear variability, and nonhabituation fear decreases did not predict any outcomes. Exploratory analyses examined fear changes during habituation and nonhabituation exposures; higher peak fear during nonhabituation exposures was associated with attenuated global improvement. CONCLUSIONS: Habituation is conceptually consistent with multiple mechanistic theories and should continue to be investigated as a practical marker of initial extinction learning and possible moderator of the relationship between fear activation and outcome. Results support the importance of functional and frequent fear measurement during exposures, and discussion considers implications of these findings for future studies aiming to understand learning during exposure and improve exposure delivery. (PsycINFO Database Record

Assessing Acute Secondary Treatment Outcomes in Early-Onset Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) in children under 8 years of age, referred to as early-onset OCD, has similar features to OCD in older children, including moderate to severe symptoms, impairment, and significant comorbidity. Family-based cognitive behavioral therapy (FB-CBT) has been found efficacious in reducing OCD symptoms and functional impairment in children ages 5-8 years with OCD; however, its effectiveness on reducing comorbid psychiatric symptoms in this same population has yet to be demonstrated. This study examined the acute effects of FB-CBT vs. family-based relaxation treatment over 14 weeks on measures of secondary treatment outcomes (non-OCD) in children with early-onset OCD. Children in the FB-CBT condition showed significant improvements from pre- to post-treatment on secondary outcomes, with a decrease in overall behavioral and emotional problems, internalizing symptoms, as well as overall anxiety symptom severity. Neither condition yielded significant change in externalizing symptoms. Clinical implications of these findings are considered.

Secondary outcomes from the pediatric obsessive compulsive disorder treatment study II.

The Pediatric Obsessive-Compulsive Disorder Treatment Study II (POTS II) investigated the benefit of serotonin reuptake inhibitor (SRI) augmentation with cognitive behavioral therapy (CBT). Primary outcomes focused on OCD symptom change and indicated benefit associated with a full course of CBT. Given that the majority of youth with OCD suffer from significant comorbid symptoms and impaired quality of life, the current study examined POTS II data for effects on secondary outcomes. Participants were 124 youth ages 7-17 years with a primary diagnosis of OCD who were partial responders to an adequate SRI trial. Participants were randomized to medication management, medication management plus instructions in cognitive behavioral therapy (CBT), or medication management plus full CBT. Acute effects on non-OCD anxiety, depression, inattention, hyperactivity, and quality of life were examined across treatment conditions. Improvement across treatment was observed for non-OCD anxiety, inattention, hyperactivity, and quality of life. Changes were generally significantly greater in the group receiving full CBT. Child-rated depression was not found to change. OCD-focused treatment lead to improvement in other areas of psychopathology and functioning. For youth who are partial responders to SRI monotherapy, augmentation with full CBT may yield the greatest benefit on these secondary outcomes. CLINICAL TRIALS REGISTRATION: Treatment of Pediatric OCD for SRI Partial Responders, Clinicaltrials.gov Identifier: NCT00074815, http://clinicaltrials.gov/show/NCT00074815.

Factors associated with practitioners' use of exposure therapy for childhood anxiety disorders.

The current study examines factors related to use of exposure therapy by clinicians who treat children with anxiety disorders. A sample of 331 therapists from a variety of backgrounds (i.e., social workers, doctoral psychologists, masters level counselors, and marriage and family therapists) completed a survey regarding use of exposure and other treatment techniques for childhood anxiety disorders, as well as beliefs about exposure and child resiliency. Although the majority of therapists endorsed a CBT orientation (81%) and use of CBT techniques, exposure therapy was rarely endorsed. Holding a PhD in psychology as well as more positive beliefs about exposure and child resiliency were associated with greater use of exposure. The results suggest that exposure-based therapy is rarely offered in community settings and that dissemination should focus on individual evidence-based principles and correcting therapist misconceptions.

Therapeutic Process During Exposure: Habituation Model.

The current paper outlines the habituation model of exposure process, which is a behavioral model emphasizing use of individually tailored functional analysis during exposures. This is a model of therapeutic process rather than one meant to explain the mechanism of change underlying exposure-based treatments. Habitation, or a natural decrease in anxiety level in the absence of anxiety-reducing behavior, might be best understood as an intermediate treatment outcome that informs therapeutic process, rather than as a mechanism of change. The habituation model purports that three conditions are necessary for optimal benefit from exposures: 1) fear activation, 2) minimization of anxiety-reducing behaviors, and 3) habituation. We describe prescribed therapist and client behaviors as those that increase or maintain anxiety level during an exposure (and therefore, facilitate habituation), and proscribed therapist and client behaviors as those that decrease anxiety during an exposure (and therefore, impede habituation). We illustrate model-consistent behaviors in the case of Monica, as well as outline the existing research support and call for additional research to further test the tenets of the habituation model as described in this paper.