brave story exposure ladder

Brave stories and exposure ladders for anxiety: a fear of elevators

My daughter successfully used a brave story and exposure ladder to face her fear of elevators. She was happy and excited when she was brave.

I discussed explanatory stories in my previous post. Now, I will present the more common type of story used for anxiety: brave stories. A brave story is about a situation, person, object, or activity about which a specific child is frightened. I will use the word “situation” in the rest of the post in place of person, object, and activity for simplicity. A brave story is used in combination with an achievable goal that allows the child to better cope with the anxiety or decrease the severity of anxiety associated with the situation. This differs from the explanatory story, which does not have a child-led goal. The explanatory story is about a situation that exists over which a child has little or no control and may be inherently scary (sibling behaviour, COVID-19) but could also be mundane (wedding). The brave story involves the child taking control, taking action and feeling brave and confident, despite feelings of anxiety. The situation is not inherently scary.

Brave stories supplement direct action. The direct action is defined as rungs on an exposure ladder. Exposure ladders are an exercise in cognitive behavioural therapy. Each rung is defined explicitly, and the child is encouraged and supported by caregivers to reach that rung. Rewards may be used after reaching particularly challenging rungs, just as you might reward yourself with drink, food, clothing, or vacations for reaching a goal. Rewarding is not bribing. Bribes are used to convince a child to do something that you want them to do (on your timeline) and may have nothing to do with feelings of anxiety (i.e. a child is tired and does not want to get into their car seat. Offering a treat for getting in the car seat is a bribe). Rewards are for a child doing something (on their timeline) that elicits a sense of pride, despite feelings of fear (i.e. a child is afraid of the car seat and after explicit steps of exposure to the car seat is rewarded with a treat for getting in the car seat, despite feelings of anxiety). The distinction between bribes and rewards can feel fuzzy but it becomes clear when you work through an exposure ladder with your child. I can see the fear written on my child’s face when she does something scary and afterwards, she is beaming and proud of herself and asks for a special treat and is motivated to try again. Alternatively, I can see that there is no fear but just tiredness, hunger, or discomfort about getting in the car seat quickly on my timeline so giving a treat is a bribe.

One of my first brave stories was inspired by my daughter’s increasing hyper-vigilance about the elevator doors closing. Months ago, my daughter, niece, sister and I got trapped in my condo building’s elevator. We were trapped for about 30 minutes while we waited for the fire department to rescue us. My sister and I maintained calm speaking voices, video chatted with grandparents and sang songs. But my daughter was clearly terrified. She reverted into her non-verbal, limp rag-doll state. After the event, we got her running around outside and she seemed okay. She also played “elevator rescue” with my husband for weeks afterwards in our home. A few weeks ago, as I was trying to maneuver a bike into the elevator, the bike fell, and the doors started closing with my daughter inside the elevator and me outside. I was able to press the call button and the doors opened before they completely closed, but I could see my daughter’s terrified face. The following weeks, I noticed that my daughter became hyper-vigilant about making sure everyone got on/off the elevator without the doors starting to close. I thought her anxious behaviour would lesson over time, but it seemed to get worse, so I decided to write a Brave Elevator Story. I also created an Elevator Exposure Ladder that my daughter and I worked on over the following weeks. Before each step, I talked about what we would do.

  1. Read story
  2. Show Lisa how I can get the doors to open by pressing buttons (outside elevator)
  3. Show Lisa how I can get the doors to open by pressing buttons (inside elevator)
  4. Put Rabbit (stuffed animal) on the elevator alone and watch the doors close. Talk about how Rabbit is safe. Mommy pushes call button and we give Rabbit a hug. Repeat.
  5. Mommy goes on elevator alone while Lisa waits outside the elevator. Lisa watches the doors close and Mommy opens the doors again by pushing the buttons (Lisa is praised for bravery and receives a sticker). Repeat.
  6. Mommy goes on elevator alone while Lisa waits outside the elevator and Mommy rides the elevator one floor down. When the doors open, Mommy calls out to Lisa that Mommy is still on the elevator. Mommy rides back up to the floor where Lisa is waiting. (Lisa is praised for bravery and receives a sticker). Repeat.
  7. Lisa goes on the elevator alone and watches the doors close and Mommy pushes the buttons outside to open the doors. (Lisa is praised for bravery and receives a sticker).
  8. Final Goal: Lisa goes on the elevator alone and watches the doors close and Daddy pushes the elevator call button on another floor. Lisa is alone on the elevator when it moves to the next floor. The doors open and Lisa sees Daddy at the new floor. (Lisa is praised for bravery and receives a sticker). Repeat.

I did not think my daughter would reach the goal. This is not the best way to start an exposure ladder. It would be much better to have confidence that your child will succeed. I created the exposure ladder based on my own idea of logical, sequential steps but without a lot of thought of my daughter’s age (2.5 years old) and developmental stage. In hindsight, I should have given this greater consideration and with a different child, I might have stopped the ladder at a lower point. Ultimately, I thought there was so much fear around the elevator that my daughter would never ride the elevator alone (at this age). But isn’t the point to alleviate some of those fears? Anyway, without more thought, I blazed ahead with the plan.

The story intrigued my daughter and we talked about the elevator a few times after reading the story, reinforcing that the elevator was safe and that Mommy can always open the doors (ok, except the freak time when it stalls and you have to wait for the fire department but that’s pretty rare and I decided I was not going to address that in this round of story-exposure-ladder action). I waited for a week or so of reading the story before starting the ladder. Each step was refused by my daughter. I would smile and say, ok, maybe next time we’ll try that. EVERY time, my daughter would wait a couple of seconds and then say, “ok [let’s try it]” and we would try the step. My daughter is one of those kids that loves to please (me). She wants to do what I suggest and has a rule-follower type personality, so this often works to my advantage. I stay enthusiastic, upbeat, and encouraging and eventually my daughter usually complies. Not everyone is so easy (as we will see in another example with my niece in my next post). But her reactions in steps 2-5 gave me more and more confidence that we could achieve the next step. That all stopped at step 7 though. I still hesitated to push her to step 8. Was this step really necessary? Does a 2.5-year-old need to ride the elevator alone? I decided I wasn’t going to push it, but one day I accidentally pressed the wrong floor button. As we were going to the wrong floor, I said, “I could jump out and you could ride the elevator all by yourself to our floor and I’ll meet you up there”. She said, “ok”, without much thought and everything happened too fast to change our minds. Away she went in the elevator while I ran like never before up the stairs to get there before the doors had fully opened. She came out grinning and gave me a hug. She was so proud of herself. She now asks to ride the elevator alone, so I purposely push the wrong floor button and jump out and take the stairs to meet her. Her bravery surprised me! Interestingly, through all the steps, the first few times of each step were clearly causing feelings of anxiety. Her fear was written all over her face as the doors would close, but she would always come out grinning and excited that she had done it “all by myself!”

I learned some valuable lessons from this experience.

  • My daughter is more capable than I thought!
  • When creating exposure ladders, it is important to consider age and developmental stage and to remember that every 2.5-year-old does NOT need to ride the elevator alone. My daughter experienced so many feelings of bravery from steps 4-7 and she stopped being hypervigilant about the elevator doors by step 7, so that is where I should have stopped the ladder. Step 8 was just a bonus.
  • It is okay to take breaks during the exposure ladder and regroup (I took a long break between steps 7 and 8).

Older children can participate in creating the Final Goal and the Rungs (steps) of the ladder, but for very young children, the caregiver will create the goal and ladder. If you have never worked with an exposure ladder for anxiety treatment, try it first on yourself. Pick something that truly gives you feelings of anxiety and fear. If you don’t have an anxious temperament or many fears, this may not be feasible for you. I have done an exposure ladder on my own phobia which helps me understand what my daughter will face at each step. This gives me a sense of empathy that is truly authentic! It is helpful to have an adult describe the feelings and thoughts for their own personal ladder rungs so you know what your child might be going through even though they may not be able to articulate those thoughts and feelings.

Before I started writing brave stories, I created a Dentist Exposure Ladder with the help of the child psychologist. One of the rungs on the ladder was to read a dentist story. I used Daniel Goes to the Dentist (the book based on the story from Daniel Tiger’s Neighborhood TV show) adapted by Alexandra Schwartz because it was one of the only stories that showed a simple cleaning visit (no x-rays, surgeries, teeth pulling, etc.). I saw how much this story helped my daughter think about the dentist and realized that a personal story (with specific language and images) would have been even better. The combination of Exposure Ladder and personalized Brave Story is more likely to succeed in reducing anxiety, converting an unknown situation into a known situation, and creating positive feelings of bravery in a child than either strategy in isolation.

In my next post, I will describe a Brave Story and Exposure Ladder for a bike trailer fear with a child less eager to please me!

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