Clinical Example 1: Social Anxiety & Reassurance Seeking Model
A note before you read on. The three narratives on this page are worst-case scenarios, written on purpose to be as frightening as the fear they came from. They include serious illness, death, and a child's fear of infecting the people he loves. That is what makes them work as exposure. If you are reading ahead rather than working through the exercises, you may want to come back to this page when you are ready.
First, we ask the individual to list and estimate a SUD rating of the triggers that evoke his anxiety. A word or phrase can be used as a short-form reference for the trigger (words in parentheses).
| Triggers | Subjective Units of Discomfort (SUDs) |
|---|---|
| Girlfriend’s frown (frown) | 8 |
| Friend pauses a long time in conversation (pause) | 7 |
| Girlfriend doesn’t text for two hours or more (no text) | 9 |
| Parents upset about my grades (low grades) | 9 |
| Friend fails to speak when passing on campus (friends ignore) | 7 |
| Making a joke with friends and thinking maybe I hurt someone’s feelings (joke hurt feelings) | 6 |
| The answer given in class may have made the professor unhappy (professor mad) | 6 |
| Forgot to call and invite a friend to join other friends for lunch (forgot to invite) | 5 |
| Haven’t stayed in touch with high school best friend (best friend) | 4 |
| I’m not being the best person I can be (offending God) | 9 |
If he begins with moderate-level SUD items, he can choose any or all of the items rated from four to six. The simple act of writing the triggers over and over again provides exposure over and over again. Notice we used the trigger’s short-form name. The student could write: friend left out, best friend, professor mad, joke hurt feelings, friend left out... Thinking about these triggers repeatedly as he writes them provides exposure repeatedly. His narrative writing loop may go something like this:
The narrative he wrote
"I saw Jake on the quad, and I thought we should get some friends together before the football game on Saturday. We could get something to eat, go to the stadium, and have our usual fun with our non-fraternity friends. Jake was going to call a couple of people, and I was going to call a couple and let them know our plans. Cara has been hanging out with us lately, but I didn’t think about calling her to join us until we got to the restaurant and Jake asked me if Cara was coming. I felt embarrassed because I hadn’t thought to call her. Jake didn’t say anything, but I could tell that he was disappointed. I wanted to apologize, but my counselor said I should resist my urge to apologize, even if I thought it was legitimate, since I seem to compulsively apologize until friends feel irritated with me. For the rest of the night, Jake didn’t seem to be having quite as much fun as he usually does. I thought he looked at me in a funny way all night, and I kept thinking I should apologize. I thought he and my other friends talked more to each other and not as much to me. We went to the game. I was afraid we’d see Cara there, and then I’d really feel bad that she wasn’t invited. Sure enough, my worst fears were realized when we were sitting there in the stadium, Cara came walking up the steps and was looking right at me. She looked surprised to see us and asked why nobody had called her. I knew I was supposed to resist apologizing, so I just told her I forgot to call. She looked hurt, and I could feel my anxiety build as she turned to Jake and said something I couldn’t hear. They both just looked at me, and she walked back down the steps. I kept seeing her in the stands below. She didn’t seem to be with anybody, and I really felt bad. I wanted to go down to her and apologize, but I continued to resist. Later on in the evening, she came back by our group and looked really lonely. I felt so bad that I had let her down. She must think I’m a self-centered and selfish person not to even think to call her to join us."
You can see that the writer should try to imagine and write about as many possible twists and turns the situation can take in order to be as anxious as possible during the exposure. However, our writer didn’t quite get his story to the worst-case scenario yet.
Here is his Worst-Case Scenario (WCS) statement:
His Worst-Case Scenario (WCS)
"Cara walked over and told Jake and me that she thought we had become pretty good friends and considered herself to be a part of our group. She looked directly at me and said she felt hurt and left out, and wouldn’t have anything to do with me in the future. I thought this would be a place to apologize, but my therapist said I should resist doing that even in what I thought was a legitimate situation. I couldn’t think of anything to say that wouldn’t be an apology, so I just stood there speechless. She looked at me like she expected me to say something, and when I didn’t, she just wiped a tear away and walked away. All of my friends just watched this like they couldn’t believe it. They asked me why I hadn’t said something to her to apologize. They must think I’m one of the coldest people they know. I think my friends must have said something to other people in our classes because people just don’t seem as friendly to me anymore. I feel really bad. I’m really uptight and don’t enjoy myself in social situations because I think the word has gotten out that I’m rude and self-centered."
Clinical Example 2: Contamination & Environmental Threat Model
Here is a second example using a contamination hierarchy list:
| Triggers | Subjective Units of Discomfort (SUDs) |
|---|---|
| Bottom or top of a shoe (shoe) | 6 |
| Trying on clothing in a store or thrift store (try on clothes) | 5 |
| Door handles and knobs at home or in public places (door handles) | 10 |
| Swimming in a public pool (public pool) | 8 |
| Touching fixtures in a public restroom (restroom fixtures) | 10 |
| Touching toilet seats at home or in a public restroom (toilet seats) | 10 |
| Touching a dirty, sticky counter (counter) | 7 |
| Touching dirt in a fishing worm container (worm dirt) | 6 |
| People coughing or sneezing in public (cough/sneeze) | 7 |
| Touching magazines in a doctor’s office (doctor’s magazines) | 10 |
| Touching books in a library or at school (school books) | 5 |
| Gym bag | 6 |
| Talking on another person’s cell phone (cell phone) | 8 |
| Using someone else’s keyboard (keyboard) | 5 |
| Getting food from a food bar (food bar) | 8 |
| Money | 5 |
Following our instructions, she repeatedly wrote out her core triggers (doctor's magazines, food bar, cough/sneeze...) and then wrote a narrative about her worst fears:
The narrative she wrote
"I put off going to the doctor’s office as long as I can because I hate being in the waiting room with really sick people. The news is always talking about swine flu. I’m right in the age group of the people most likely to get it. I have a regular physical scheduled, and I’ve put it off so much that my doctor’s office said they won’t schedule with me again unless I have my physical. I walk to the end of the street to catch the bus, and a wino comes around the corner and bumps into me. I want to go home and take a shower, but I’ll get charged if I miss my appointment. They may drop me as a patient as much as I’ve rescheduled. I can just feel my skin crawl with whatever disease he may be carrying. My palms get sweaty, and my heart rate goes up. My anxiety is so high that I think about turning around again, but I know I’m supposed to resist this. They call it avoidance, and they say it becomes a compulsion just like washing my hands. I get on the bus and accidentally touch the handrail. I fumble around to put the token in the machine and drop it on the floor. God knows what has been on some winos' feet or if somebody stepped in dog mess when they walked across the grass. I think I’m going to have a heart attack because I’m feeling so anxious about all these germs. I can’t believe I don’t even have any hand cleaner. Now I’m stuck on this bus, and these dirty little kids are sitting right across from me. I watch one of them wipe his nose with his hand and then grab the handrail. Did I touch that handrail? I think I’m going to get sick. These kids are about the age of those kids the news said had cases of swine flu. If anybody can catch anything, I’ll be sure to get it. I get to the doctor’s office, and it’s crowded. There is one chair available, and I wonder who was sitting there previously. I started to just stand, but the nurse said to have a seat, and we’ll get you to update your personal information. So, I sit in the chair, and I just know somebody may have been exposed to swine flu. I hear somebody sneeze and cough. This is a nightmare. I feel like I’m getting warm. I can’t stand these feelings of anxiety. I wonder if I’ve already been contaminated. I’m feeling flushed and a little nauseous. I’m sure I have flu symptoms."
Here is her completed Worst-Case Scenario (WCS):
Her completed Worst-Case Scenario (WCS)
"I went to the doctor’s office to get vaccinated against swine flu. They say you’re not supposed to be able to catch it from the vaccination, but I feel like I have flu symptoms. I take my temperature, and I do have a fever of 101. I called my doctor’s office, and they’re closed today. She’s on vacation. I decide to go to an urgent care clinic. I’m feeling weak and tired, and I’m afraid I have swine flu. The urgent care doctor told me he thought I had flu-like symptoms. He swabbed my nose and throat and said he’d send the sample to the lab. He told me to go home, drink plenty of fluids, and rest. I went home, and I just felt hotter and sicker. I took my temperature, and sure enough, it hit 102. I called the urgent care doctor, and he was off his shift, so I decided to go to the emergency room. They took one look at me and saw how sick I was, so they admitted me to the hospital. Now, I’m really worried about dying. This all started because I thought getting a vaccination would help. It looks like my good intentions are going to kill me. They’re pumping fluid into me and giving me medicine. I think I’ve developed pneumonia. My doctor came back from vacation, and she tells me I’m in pretty bad shape. I should let my family know how bad it is because it could be fatal."
Clinical Example 3: Contamination Model (Child Perspective)
Alternatively, a child's WCS text highlights how the fear of spreading the threat to loved ones takes psychological center stage instead of death:
A child's Worst-Case Scenario (WCS)
"I am sitting in my classroom and looking at the kids around me. One of them is picking his nose, and the other is coughing a lot. I know lots of kids have been missing school because they are sick. My mom says lots of people have the flu. I can’t concentrate because all my brain thinks about is how many germs are all over the place at school and in my classroom. I feel like I can’t go anywhere or touch anything in the school because everything has flu germs on it. I can feel my heart beating faster, and it gets a little hard to breathe. The bell rings, and my teacher says it is time for lunch. My belly is growling, but it also feels icky when I think about all of the germs. I make sure not to touch anything on the way to the lunchroom. I even hold my breath sometimes, so I don’t breathe in any germs. I use my Germ-X seven times before I get to the lunchroom and then keep my hands in my pockets to protect them. I am scared that the germs will get all over me and maybe inside of me, and I will spread them to my family and my house when I get home. When I get in line for lunch, I feel shaky. I want to run far away from the lunch trays that all of the kids have touched, but I am hungry, too. I get a piece of pizza and then rub the germs on my hand onto my pants. I can almost feel it spreading on them. I sit down and use Germ-X, then take a bite of pizza. I think the pizza is germy. It doesn’t feel right going to my stomach, so I do not eat anymore. For the rest of the day, my tummy feels funny. I know the germs are getting into my blood and taking over my body. When I get home, I tell my dad I don’t feel very good. He takes me to the doctor, and she says that I am sick and will never get better. She says that germs are all over me and inside of me forever. I know I will always feel gross and never get away from the germs. I want to cry because now I will spread germs everywhere for the rest of my life."
Following the therapeutic plan, clients continue to work their way up the list of triggers and eventually include the moderately high SUD level (seven) to the highest SUD of ten. Our examples are much shorter than a ninety-minute session, but they should help you begin to get the idea.
Our clients with mild to moderate levels of anxiety and without anxiety disorders tend to find they quickly benefit from the same type of exposure we use with our clients who suffer from anxiety disorders. To get the complete benefit of exposure, clients move on to in vivo exposure looking for opportunities to confront their fears repeatedly until their SUD level reaches two or less. Most find in vivo exposure much easier to face because of the work they’ve done in writing out their fears.