Table 1.

Observer Rated Therapist Behaviors

Behavior	Definition
Fear Increasing
Encourage Approach	Therapist facilitates patient physical or mental contact with the exposure stimulus, including redirection to the exposure task (e.g., “Try to keep looking at the picture”), discouraging avoidance or rituals (e.g., “Remember to resist the urge to ask for reassurance”), requests to describe fear content (e.g., “What are the worries saying right now?”), discussion of the exposure stimulus (e.g., “Ok, we’ve got the trash can out”), or other actions that keep the patient engaged with the exposure task.
Intensify	Therapist changes the exposure task to make it more difficult (e.g., asks patient to put contaminant on both hands instead of one) or makes a statement likely to increase fear by providing new relevant information (e.g., “This carpet hasn’t been washed for a really long time”) or new relevant opinion (e.g., “Wow, that is a lot of vomit”).
Reduce Parent Accommodation	Therapist discourages parent accommodation behavior during the exposure; this could occur independent of or in response to-actual occurrence of parent accommodation (e.g., “Your mom is going to try and resist any OCD questions”).
Fear Neutral
Teaching	Therapist provides brief instruction about a CBT principle or symptom that relates to the current exposure (e.g., “Remember, your job during exposures is to practice ‘riding the anxiety wave’”). Teaching that is not relevant for the current exposure or that functions as a distraction from the exposure would be coded as unrelated talk.
Externalizing	Therapist refers to OCD or anxiety as being separate from the patient, which may include a patient-selected name if developmentally appropriate (e.g., “You’re the boss of Mr. Worry”). Externalizing was coded only when occurring in a statement without another code of interest. For example, the statement “Don’t let those worries trick you into giving up!” contains elements of both externalizing and encouraging approach but would be coded as encourage approach.
Changing Anxious Thoughts	Therapist leads the child to use a cognitive or coping strategy to manage fear during the exposure (e.g., evaluating the likelihood of a feared consequence, using coping statements such as “I am brave”). This code is used when the therapist elicits or prompts patient use of a strategy; if the therapist supplies fear-reducing information (e.g., stating that the actual risk is low) it would be coded as accommodation.
Fear Decreasing
Accommodation	Therapist changes the exposure task to make it less difficult (e.g., instructs patient to decrease contact with the exposure stimulus) or makes a statement likely to decrease fear by providing new relevant information (e.g., “I eat this all the time and nothing bad happened to me”) or new relevant opinion (e.g., “I think you’ll be ok”).
Unrelated Talk	Therapist makes a statement that is not related to the current exposure and could serve to decrease patient focus on the exposure task. Content may be general (e.g., “What are you guys up to this weekend?”) or include CBT components with limited relevance for patient experience of the ongoing exposure task (e.g., extended psychoeducation about etiology of anxiety, planning homework for a different exposure).
Encourage Relaxation	Therapist leads the child to use relaxation techniques, such as taking deep breaths, muscle relaxation, or pleasant imagery (e.g., “Remember how to control your breathing?”).