Central Therapy Strategies

Central Therapy Strategies of this Play- and Humor-Infused Exposure Therapy Approach

Develop, use, and revise a Fear Ladder:

1. Generate a list of situations or “steps” to explore the target scenario. Think about small steps that together bring the child closer and closer to their feared object or situation, perhaps including more indirect exposure including with toy versions of the objects, video recordings, and eventually real objects.
2. Fill in ladder with trigger scenarios to re-create in session with the most tolerable situation at the bottom (e.g., play with toy toilet [low]; listen to toilet flush audio [low]; use doll on real toilet [medium]; flushing real toilet [high]). Note: steps will involve more or less play/toys depending on the child. A variety of modalities may be used (mp3 files of noises, puppet play, parent); see manual.
3. Ask parent to rate the level of emotion the child shows or would likely show, from 0-10, for each step; rearrange as needed. Note: If child has little mastery of pretend/symbolic play, make play scenario as close to the actual situation as possible; e.g., form hierarchy using a real toilet
4. Gradually take the steps up the fear ladder within playful routines.

Use play and humor to faciliatate exposure:

1. Learn what the child finds funny, enjoyable, or soothing
2. Playfully pretend to be fearful of the object or situation and/or act this out with a puppet, doll, or action figure, as a way of “joining” the child in their fear playfully.
3. Incorporate the child’s interests into play routines that can be carried out with the feared object. For younger children, these may be games like stop/go games or peek-a-boo. For children who have some pretend play this may include dolls or action figures and pretend scenarios. This may also include using the feared object in unusual ways that are not how it is typically used (e.g., use a hair brush or toy vacuum cleaner as a guitar)

Stay carefully attuned to the child’s anxiety level:

1. Try to stay just under the child’s threshold for upset
2. When it seems like the child is not anxious anymore about a situation or stimulus, do it a few more times to solidify the child’s non-anxious response.
3. If noticeable anxiety is present during an exposure, move to an earlier step on the fear ladder until a playful routine is well-practiced, and then try moving up the fear ladder again

Entice rather than command engagement

1. If the child is not engaged in the play related to their fear, take a break from that play and try playing with something else that interests them or in a different way that is enticing to them
2. Then, creatively integrate the feared object into that play
3. The goal is to be playing in an attuned way that results in their engagement, rather than to direct them to engage