A reflection of an undergraduate intern’s experience serving as a confederate in her first exposure therapy session.
By: Isabella Xie, ATSA Psychology Intern 2020
Originally published August 7, 2020
“Would you like a smiley face or a star?” I asked the little girl sitting in front of me as I held out two stickers. I counted up to 8 seconds of silence in my head until a tiny whisper bubbled out of her. “What was that?” I asked again. “A star.” she said this time, a little louder. “A star!” I reflected with the biggest smile I could muster. “Thanks for telling me!”
This was my second exposure session serving as a confederate for therapist Cate O’Leary, LCPC, and I already felt more confident using the skills I had been taught in training at Advanced Therapeutic Solutions (ATS) to interact with children with selective mutism. Selective mutism is an anxiety disorder where children fail to speak in social situations despite speaking at home; in fact, some are even chatterboxes at home, which is a marked difference to how they are in public settings, such as in school where they are mute. Having this disorder could significantly interfere with the child’s social and educational functioning, and if left untreated, could increase their risk of developing other anxiety disorders and depression later on. Fortunately, selective mutism can be treated by exposure therapy.
Exposure therapy is an evidence-based treatment for phobias and involves extinguishing fear by approaching the phobia, usually in successive steps. Selective mutism can be considered a phobia of speaking to strangers. Therefore, exposure therapy for selective mutism guides the child through successive steps toward verbal communication with people (e.g., teachers, strangers, peers) with whom they would otherwise be mute. The role of the confederate is to assist the therapist in simulating real-life situations for the child as an exposure task to foster generalization of speaking across people, places, and activities. I vividly remember being a confederate in my first ever exposure session via telehealth with clinical psychologist, Carmen Lynas, Ph.D. For the session, Dr. Lynas instructed me to play a kindergarten teacher role for a little girl (named Annie for the sake of this post) who is starting kindergarten in the fall. Since school will occur online instead of in-person due to COVID-19, the exposure task was to occur via telehealth. I was to do a story time activity, similar to a story time that occurs in kindergarten. Meanwhile, Dr. Lynas would turn off her video during the exposure task and pretend like she wasn’t there, although she reassured me she could still see and hear, would send feedback and instructions over our private zoom messages, and would intervene as needed. The goal was to have Annie verbalize with me, someone she’s never seen before.
I was taken by surprise by the amount of responsibility I was trusted with as an undergraduate intern. To interact with Annie by myself? Naturally, I had doubts at the back of my mind about my own abilities. I was scared of asking yes/no questions when I shouldn’t, missing a labeled praise, or worse, failing to come up with anything to say at all. And what if Annie is unwilling to speak to me even after a series of prompted questions?
Upon realizing my own fears, I was suddenly struck by what it must feel like for Annie. As much as it felt scary to me, it probably felt ten times scarier for her to be left “alone” with me, a complete stranger. Realizing this gave me strength, and I was determined to be the model of bravery for her.
I was both excited and nervous for this task, but most importantly I really wanted to do it well. Thankfully, as part of our internship training, Dr. Lynas had provided us interns with the training necessary to act as confederates in exposure therapy sessions for children with selective mutism. In preparation for my session with Annie, I spent time reviewing the skills that were taught in our ATS training, as well as reviewing Dr. Steven Kurtz’s selective mutism course to consolidate my knowledge of the CDI (Child-Directed Interaction) and VDI (Verbal-Directed Interaction) skills. In addition, I had my friend role play with me whilst I practiced reading through stories and pausing in between for opportunities to ask questions and interact with my friend as they played the role of the child.
During the session, I realized that my worries were overblown. Annie was a lot more responsive than I had imagined. Her verbalizations were a huge validation that I was exercising the skills correctly, and that she was generalizing speaking to a new person. As the session went on, I could feel Annie open up and become more comfortable with me. Her bravery and liveliness were reassuring, and I could feel myself become more confident. Words came to me more and more smoothly and naturally. Annie was my support as I stepped out of my comfort zone as much as I was hers. Was I nervous? Yes. But it didn’t seem to matter anymore.
It was in that hour that I truly realized the spirit and meaning of using one’s brave. Nelson Mandela once said: “I learned that courage was not the absence of fear, but the triumph over it.” Fear and anxiety are a part of the human experience, but being brave isn’t about being unafraid, it’s about learning to speak, to live, to achieve our goals in the presence of fear. Despite being mute for two years in preschool, and a history of experiencing significant anxiety and distress when faced with the expectation to speak to a stranger, Annie spoke to me. As Dr. Lynas says: “In our fear we find our brave, in our brave we find ourselves.” This is what these children with selective mutism show us with their voices.
I am grateful to ATS for providing me with these clinical experiences and training that’s hard to come by for college students. Realizing how happy I am working alongside the therapists at ATS, interacting with these children during their exposure sessions, and how much I look forward to each confederate opportunity is a great comfort. It is confirmation that I am choosing the right career: to become a child and adolescent clinical psychologist. As much as the children at ATS are learning to find and use their brave, I too am learning to find my own brave in overcoming fears, doubts, and anxieties. I am reminded every day that as a coping model experiencing shared vulnerability with these children, I am learning so much from them. We are not fearless, and things don’t always turn out perfectly on the first try, but learning to accept adversity is a part of growth itself. We learn that we are strong enough to stand with (not up to) our fears and anxieties, and through practice, we can persist despite difficulties.
About the Author
Isabella Xie is a senior at Johns Hopkins University, where she will be graduating with a double major in psychology and cognitive science, and a minor in music. After graduating, she hopes to pursue a doctorate degree in clinical psychology and become a child and adolescent clinical psychologist.
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