By Don Vardell, executive director, Mountain Valley Treatment Center

According to the National Institute of Mental Health, eight percent of US teens suffer from an anxiety disorder during their school-age years, with symptoms typically beginning at age six. Only 18 percent of these teens seek mental health treatment. As this statistic will no doubt increase, the need for specialized anxiety treatment in outpatient and residential environments will grow. Although outpatient therapy can achieve results for some, a short-term and intensive residential treatment environment is warranted when the anxiety causes major interruptions in daily living, such as repeated school or social avoidance. A specifically focused residential treatment center or RTC can provide comprehensive and consistent clinical interventions and support that can’t be achieved in a home-based community setting.

Many parents of children with debilitating anxiety can trace the start of symptoms to elementary school, but often don’t find effective help until early adolescence, when academic requirements become more challenging. As a result, families resort to managing the anxiety and behaviors in accommodating ways that unknowingly make it worse. Although many teens in RTCs have had outpatient therapy, their results have been limited, because many community-based clinicians are not well-versed in effective treatment modalities for anxiety disorders. Additionally, the work to “retool” the family to stop accommodating their child’s anxiety may be difficult to do consistently in a nonresidential setting.

Anxiety and related disorders, such as phobias and OCD, are treated with cognitive behavioral therapy (CBT) approaches, specifically exposure and response prevention or ERP, a treatment technique that was developed to help people effectively confront their fears. When people are fearful of something, they tend to avoid the feared objects, activities, or situations. Although this avoidance might help to reduce feelings of fear in the short term, it can exacerbate such feelings in the longer term, sometimes generating behaviors that become detrimental to everyday life and well-being.

Exposure therapy is designed to help break the pattern of avoidance and fear. Gradual exposure to the feared objects, activities, or situations in a safe and nurturing environment can help adolescents  decrease avoidance, recognize irrational thoughts and behaviors related to fears, and engage in healthier and more fulfilling activities and relationships. Although ERP can be implemented in an outpatient setting, a controlled and focused residential treatment environment can provide better results for severe anxiety. ERP in a residential setting will in some ways look similar to what may have been done with an experienced therapist at home—gradual and repeated exposure to the anxiety causing stimulus, time for habituation to occur, and anxiety symptoms decreasing—however, a residential environment allows for repeated in-vivo (real world) and more intense exposures where cumulative data can be collected. An RTC also ensures a greater number of professionals will be working with the adolescent and family system, which is hard to achieve with home-bound teens.

When a family and independent educational consultant (IEC) have determined that a residential placement is needed, a program with a structure and model that supports the delivery of ERP should be considered. A comprehensive and specialized anxiety treatment program that utilizes ERP would typically include:

• Multiple and extended ERP groups weekly where students receive education about ERP and participate in exposure activities

• Cohort work on exposure scenarios where two or more students can develop an exposure plan for similar fears

• Intra- and intersession exposure work with a trained therapist or specialist and opportunities to “rehearse” confronting fears in vivo

• Data collection during the exposure assignments that includes cumulative rating of the anxiety (scale of 1–10), documenting and communicating thoughts, describing physical sensations, and acknowledging safety behaviors

• Exposure work supplemented by weekly individual and family therapy.

Although a program that specializes in anxiety with a strong clinical component is paramount, the programmatic structure of a residential program should also be fun and include an environment to support exposure therapy. Consider whether the program includes experiential and recreational activities to develop skills and explore passions and other evidenced-based elements to help with anxiety, such as mindfulness activities like yoga, nutrition education and healthy meals, and fitness and outdoor activities. Programs should also have the ability to support the academic needs of the student.


As a student and family become immersed in a residential treatment experience, they will pick up a new vocabulary. The following are examples of terminology related to activities used in specialized anxiety treatment:

Fear Hierarchy. A list of a student’s phobic situations and objects ordered from the least to the most fear-provoking. Early on in residential treatment, a therapist will work with a student to develop their Hierarchy to inform the gradual exposure therapy plan.

Safety Behaviors. Actions to prevent disaster that inadvertently prevent the disconfirmation of maladaptive threat beliefs. Safety behaviors can “work” for a student, but they will not effectively expose them to the feared situation; therefore, they do not help the student develop healthy coping strategies for the feared object or situation. For example, someone who has a fear of public speaking may develop a safety behavior, such as having to wear a certain article of clothing before the presentation, but will not develop the ability to make a presentation without the clothing article, thus continuing the cycle of anxiety around public speaking.

SUDS (Subjective Units of Distress Scale). A relative measure of anxiety, usually on a scale of 0–10. Each student develops their own scale based upon their personal physiological, cognitive, and behavioral symptoms when faced with an anxiety-provoking situation. This scale is used during exposure therapy to track habituation and desensitization to fear stimuli.

Interoceptive Exposure Therapy. An exposure therapy process commonly used to treat Panic Disorder. During interoceptive exposure, a person purposefully and systematically induces the physical symptoms of panic and anxiety, absent from any actual fear stimuli. This assists in promoting desensitization to the uncomfortable (and feared) physiological symptoms that often play a role in the development of panic attacks.

Imaginal Exposure. Exposure to the fear stimuli through a discussion about the stimuli, conjured images of the feared stimuli, or thoughts of the feared stimuli aided by written or recorded verbal material. This process allows people to slowly face their fears with a greater sense of control and safety. Imaginal exposure is often used as an entry into exposure therapy when a person is highly fearful and avoidant. Imaginal exposure can also be effective in treating fears that cannot be readily reproduced (e.g., anxiety associated with a past experience or a specific person or place). A student with a fear of vomiting (Emetaphobia) will be exposed to situations where he/she vomited by writing a story about the situation, gradually adding more information about the situation/scenario, and identifying rituals associated with avoiding those situations. Exposing the student to sounds of vomiting; fake vomit; and actually replicating a vomiting situation, such as emitting water out of the mouth, will support the exposure work.

Habituation. Describes the process of anxiety reduction (achieving physiological homeostasis) over time without the use of safety behaviors or avoidance of the feared stimuli. Experiencing anxiety habituation in the face of a fear stimulus is believed to help develop new learning in regards to the actual threat (or lack thereof) posed by a certain object or situation.

Intrasession habituation describes achieving habituation during a single exposure therapy challenge. For example, a SUDS peak rating of 8 out of 10 and a final SUDS rating of 4 out of 10 when a person is exposed to a fear stimulus.

Intersession habituation describes achieving habituation between exposure therapy challenges, thereby reducing the unwanted fear response or distress during the subsequent exposure challenge. For example, “Yesterday when I saw the dog, my anxiety peaked at 8 out of 10. Today when I saw the dog, my anxiety only peaked at 6 out of 10.”

In Vivo Exposure. Simply putting the student in real-world situations that will evoke the fear multiple times whereby the self-rating of the student’s anxiety will reduce.

Expectation Violation. A concept that is highlighted when completing exposure challenges to promote new learning. This concept aims to highlight the discrepancy or mismatch between someone’s feared outcomes of an exposure challenge and the actual outcome. This concept is especially important to highlight when the person has difficulty experiencing anxiety habituation during exposure challenges.

Family Accommodation. Coping strategies the family system engages in to manage fear-provoking situations at home that actually reinforce the feared object or situation. One example is a family that eliminates green food items from the entire house because the student has a fear of green-colored food. A residential anxiety treatment program will include significant work with the family on eliminating accommodating behaviors and learning how to support the student’s exposure work during and after treatment.

No matter what treatment environment is warranted or selected, creating a collaborative network of professionals and providers will net the best outcome. Residential programs typically work alongside IECs and other referral sources as well as parents and at-home providers to support a student while at the program and through a successful transition. As awareness and impact of anxiety disorders grows, knowledge of effective and available programs should as well.

Don Vardell can be reached at [email protected] or


Wilson, Reid and Lynne Lyons. 2013. Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle and Raise Courageous & Independent Children. Arlington, VA: Health Communications Inc.

Abramowitz, Jonathan S.,  Brett J. Deacon, and Stephen P. H. Whiteside.  2011. Exposure Therapy for Anxiety: Principles and Practice. New York: The Guilford Press