“Exposure therapy is such a hopeful treatment,” said Dr. Elizabeth Brannan, an associate professor of psychiatry and human behavior and clinician educator at Brown, and the intensive services lead at the Pediatric Anxiety Research Center. “We have kids coming to us whose entire lives are consumed by anxiety or OCD, and two to three months later, they’re going to school and living their lives again. The difference can be shocking.”

Facing fears where they live, with support

Exposure therapy draws on the body’s natural capacity for habituation. Facing a fear is like jumping into cold water, Brannan said: uncomfortable at first, but tolerable with time. The trick is to find creative ways to help a child confront and stay in the feeling of anxiety until it abates. For someone with a phobia of vomiting, for example, an exposure could range from spelling the word “vomit” to watching a video of the act to facing a specific trigger.

Exposures in the center’s intensive program are custom-designed and delivered by a team of psychiatrists, psychologists and trained coaches, for five days a week over two to three months. In addition to regular individual therapy and group sessions, exposure coaches visit the patient at home. The coaches eventually teach families how to lead exposures themselves. 

More than three-quarters of the severely sick kids in the center’s intensive program respond to exposure-based treatment, according to Brannan.

The researchers are testing virtual reality as a training tool to simulate exposure sessions for therapists, and studying transcranial magnetic stimulation — a non-invasive way to activate parts of the brain with magnets — as a way to help the hardest-to-treat patients benefit from exposure therapy.

Freeman calls the team-based model — of doctoral-level clinicians (such as a psychologist with a Ph.D. or a psychiatrist with an M.D.) supervising exposure practitioners who can go virtually anywhere — the center’s most important innovation since its earliest trials. That’s because the approach treats anxiety where it lives: in schools, churches, stores, beaches and more. The Brown researchers recently concluded a five-year study of the effectiveness of this type of program.

In late 2024, researchers at the center were awarded an $11 million federal grant to test the model in community-based health care settings across Rhode Island, which serve more socioeconomically diverse populations. The findings, the researchers hope, will justify insurance coverage for home visits.

While the treatment is accessible to children living in Rhode Island, families from all over the country come to the center, often after a wait, given the demand. Brown faculty continue to pilot and study solutions to the shortage of trained mental health professionals, including a remote training program for individual therapists as well as clinical staff at community centers, schools and psychiatric hospitals. 

“We need to be going outside the safety of our academic medical setting and doing everything we can to treat everybody,” Freeman said.

This story was adapted from a Medicine@Brown feature about the Pediatric Research Anxiety Center.