If you or your child experiences significant anxiety you’ll know how incredibly challenging it can be to manage. There is hope, as cognitive behavior therapy, specifically exposure therapy, is a treatment that has shown success rates around 70% for more than 50 years. These “successes” tend to mean not only a significant decrease in anxiety, but a change from a “clinical” level of anxiety to a non-clinical level. Of all the issues that come up in the mental health field, psychologists are by far the best at treating anxiety.
Sadly, even though exposure therapy has been proven to be highly effective, it is incredibly under-utilized in the mental health community. If you go to see a provider for anxiety treatment you will likely not receive exposure therapy, and possibly won’t even receive any form of Cognitive Behavioral Therapy at all.
There are many reasons why. One of the major roadblocks is the belief that exposure therapy is unpleasant for patients. I’ve already discussed how this is not the case at all. Another reason which I will focus on today is the challenge of finding the motivation to deliberately face anxiety. I can understand that this can be a challenge for anyone, but it is especially problematic for youth. At times they don’t want to be in therapy, but more often than not they have tried many things to deal with anxiety and not much has worked. As a result, it’s often parents who bring them to treatment.
Parents want their children to feel better, and for an anxious youth, exposure therapy is their best bet. However, for a child/youth to benefit from exposure therapy, they need to do three things:
- Show up to therapy
- Participate in exposures during sessions
- Participate in exposures outside of sessions
So how do we help them do this? Well, the purpose of today’s article is to help identify a key motivation and engagement strategy used to achieve these three outcomes. Please remember, although I’m writing this for parents of anxious children and adolescents, the principles involved can be applied to adults too. The strategy is called contingency management, but to understand this we first need to talk about rewards.
For decades this has been a key element of treatment and self-help. Rewards, also referred to as reinforcers are absolutely critical to make progress, and not only do we have evidence that they increase motivation for treatment, they also validate the intense efforts put in by individuals. Combined, these two effects result in treatment that is more likely to be successful. You have to use reinforcement to get the best results. As the saying goes “You catch more flies with honey, than vinegar.”
What is a Reinforcer?
A reinforcer is anything that occurs alongside an act that increases the probability that act will occur again.
Positive Reinforcer = Having completed a behavior, give something the person wants (e.g. food, games, praise) and if it’s a reinforcer, that targeted behavior will increase.
Negative Reinforcer = Having completed a behavior, take away something the person wants to avoid (e.g. an unpleasant sound, a frown) and if it’s a reinforcer, that targeted behavior will increase.
Both are good things because they increase the chance of the behavior you want! Thus, some people are motivated to play well in sports to earn praise, whereas others are motivated to avoid critical comments!
Note: Reinforcements vary and are highly individual. Food may not be reinforcer if you’re full.
Size of Reinforcement
You should provide the smallest amount of reinforcement as you can get away with to avoid satiation. If you give too strong of a reward for too little behavior, future motivation will be limited. The problem is, now they are going to want something of similar value every time they complete a similar task in the future. So, don’t give a Playstation as a reward for doing one thing!
Common Areas that can be Reinforcing
- Tangible (e.g. food, money)
- Privileges (e.g. bedtime, movie choices, screen time)
- Social (e.g. time with friends, being read to)
- Avoidance of roles (e.g. don’t have to do chores)
What is Contingency Management?
Simply, it is using rewards as described above to help promote certain behavior. The rewards can only be given once certain behavior occurs: That is, rewards are given contingent on desired behavior.
Once you know what you want to reinforce (e.g. your child completes their exposure task that day) then you should immediately provide reinforcement when they do it. The reinforcement is contingent on the behavior and only happens if the behavior occurs. So, if your child completes their exposure, they immediately earn 20 minutes of screen time if that is the reinforcer. If the behavior does not occur, for example your child doesn’t complete their exposure task, then no reinforcement is given. This is the essence of contingency management in the context of using rewards.
If your child doesn’t meet the behavioral goal, withhold the reward until they next complete it. For example, if your contingency is that your child only gets screen time once they have done one exposure at home and they didn’t do this on Monday, they can still earn the reward on Tuesday provided they complete one exposure on that day.
Note: Changing your own behavior is really hard. One reason is that rewards are often not truly contingent. For example, if I say to myself that every day I exercise I get to eat an ice-cream, the problem is that I can easily access the ice-cream regardless of whether or not I have exercised. If you can make it so that others are able to hold you accountable you’ll likely be much more successful. That’s why when parents use contingency management with their kids it tends to be far more successful. Because they are more able to hold things truly contingent.
How to Use Contingency Management
There are two main methods that I like to use. Either a “rewards menu”, or what’s called a “token economy”.
Before you choose, first create a list of things you/your kid wants. Here are some examples
Tangible (e.g. food, money)
- $10 Amazon voucher
- Buy one iTunes song
- Cinema ticket
- New piece of clothing
Privileges (e.g. bedtime, movie choices)
- 15 minutes later bedtime
- Get to choose what’s for dinner
- Choose what TV show the family watches
- 30 minutes extra screen time
Social (e.g. time with friends)
- Have a sleepover
- Get to have extra family time
- Can go out with friends after work/school
- Avoidance of roles (e.g. don’t have to do chores)
- Don’t have to do the washing up
- Don’t have to make breakfast/lunch
Click here for some other common ideas for rewards.
Using a Rewards Menu:
Once you have made this list, decide what needs to occur in order to earn each reward. This is called the target behavior. For example, if you want your child to face a scary situation as an exposure once per day, then give them a reward for trying it each day. This is called fixed interval reinforcement, and is pretty effective. I also recommend having a bigger reward to work toward for meeting some bigger criteria. For example, if you achieve the main goal (e.g. your fear is spiders and you manage to hold a spider for 30 seconds) then getting a new pair of shoes for achieving that could be a great idea. That way, you have small rewards for the everyday achievements, and larger rewards for the end goal.
Using a Token Economy:
Instead of just giving straight rewards, I often prefer a token economy. With that list of rewards, assign each reward a number of points. For every exposure your child does, give them a point. Once they earn enough points, they can swap them for prizes. These swaps need to happen every two weeks in order to prevent having so many points that they just become worthless. What I mean by this is imagine your child has earned a million points. If doing an exposure is worth 1 point then they are probably not going to be motivated anymore.
Some tips on rewards menu and token economies:
- You must give the reward/points as soon as possible once earned
- I’d highly recommend writing down what was earned. Not only does this help keep track, but it’s very validating of the progress made
- You can NEVER take points or rewards away. Once they are earned they are earned
- Over time, fade out the points/rewards. Thus, if one exposure earned one point, it now takes three exposures to earn one point
- If they don’t complete the exposure, don’t get angry or frustrated. Just don’t give the reward.
- Only give contingencies that you are 100% prepared to follow through with.
- NEVER punish someone for not completing an exposure.
More Advanced Strategies
In addition to the rewards for accomplishing daily exposures, and for completing bigger accomplishments there are also several other strategies you can use to reinforce target behaviors.
Jackpots: Now and again, give a bigger reward spontaneously. Let’s say your kid does an exposure, and then for the sake of it does another harder exposure. Just because they were in the mood. Or they have just been trying very hard for a long time. Feel free to give a bonus (and bigger) reward. Save this for breakthroughs and use very occasionally. To give some context for frequency, I’d suggest that this is a once per 6-12 months occurrence.
Intermittent Rewards Level 1: You can’t give a reward every time an exposure is completed. As such, over time you need to ask more of your child to get the reward. For the first few days, you could give a reward for each exposure, but after a few days it will take two exposures to get the same reward. This is intermittent reinforcement and is actually more powerful for getting sustained behavior change. You will probably naturally do this. For example, if you’ve ever trained a dog to sit, you will have given it a reward each time, and then phased this out over time until your dog just sits when asked.
Intermittent Rewards Level 2: Even better than phasing out the rewards, is to give rewards unpredictably. This is the most motivating method. This is why gambling is so addictive. You win, but never predictably, and you never know when it will happen. So you keep trying. My favorite way to accomplish this is the “Jar of Uncertainty”. Together with your child, write at least 20 exposures on small pieces of paper and scrunch them up. These should be of varying difficulty. Some should be difficult, some should be easy. You want maybe 5 easy ones, 10 middle ones, and 5 hard ones. In addition, write in two reward cards, one small and one bigger. Then, each night you have to pick one random paper from the jar to do. What’s cool about this is often the kid is excited because they can just win a reward. How fun!
Specific Goals: Goals need to be specific and clear. “Complete one exposure” is not a good goal, so it’s difficult to reinforce. I promise you’ll get told “I’ll do it later” if you use this method.
“You have to look at 3 different videos of spiders without looking away from the screen, by 7pm,” is much more behaviorally specific goal. To know if it’s a good goal ask yourself “how will I know for sure that they have earned their reward?”
Developmentally Appropriate: Expectations and rewards should be developmentally appropriate. Younger kids will often comply with the expectations of exposures, but having rewards makes it exciting and fun. I promise you, if you get the rewards list right and follow through with the above principles, then the younger child will be highly engaged and treatment is likely to be successful. If you have a teen, instead the treatment is most likely to be successful if the teen is self-motivated. But rewards really help the process. Again, if you get the rewards right, your teen will be SO much more engaged in the process and will enjoy it. The message is clear: For both younger and older kids, rewards help.
Predictable: If your child doesn’t earn the reward, they may get upset. Sometimes they may get very upset. Regardless of this, NEVER give the reward unless they have completed the exposure. Be predictable in this way.
This article covered the basics of rewards and how to use contingencies to help with exposure treatment for anxiety. Hopefully it has intrigued you to consider how this strategy can enhance treatment by making it way more fun and rewarding.
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