Anxiety disorders impact 1 in 3 youths by the time of adolescence, and can lead to depression, substance use, school issues, and suicide risk (Ahlen and Ghaderi, 2020; Merikangas et al., 2010). Specific phobia is the earliest occurring and most common anxiety disorder and increases risk for later onset of other anxiety disorders (e.g., separation, social, generalized anxiety disorders), OCD, depression, and substance abuse problems (Barzilay et al., 2020; Bushnell et al., 2019; Wetzer et al., 2021). Exposure therapy is the standard treatment for specific phobia (Ollendick and King, 2004; Wolitzky-Taylor et al., 2008), but many still struggle with symptoms even after treatment. For exposure therapy to be effective, youth with specific phobia must actively approach feared situations to learn that feared outcomes do not occur. Therefore, strategies to facilitate approach behaviors during exposure therapy may improve treatment outcomes.

Self-distancing (SD) is a technique that may help youths approach their fears in exposure therapy. SD utilizes third-person language to enhance a person's psychological distance from self, helping them to "take a step back" from emotional situations to take a more objective perspective. In community samples, SD has been found to boost determination and persistence during difficult tasks, including those that induce anxiety (e.g., giving a speech). However, SD has yet to be tested as a strategy for helping clinically anxious youth engage with exposures in the context of therapy. Additionally, objective measures of approach are needed for measuring and modifying novel exposure therapy augmentation strategies, such as SD, to improve treatment outcomes.

This study will examine if SD increases the ability to approach feared stimuli during exposure therapy to improve response to treatment. Investigators will test SD in 20 youths (12-17.99 years) with specific phobia of spiders randomized to exposure therapy with or without SD. Exposure therapy will be delivered using a one-session treatment (i.e., OST) which includes 7 increasingly challenging exposure tasks (i.e., from observing to touching a spider), adapted from prior work (Ollendick and Davis III, 2013). In the SD condition, patients will engage with exposure tasks from a self-distanced view (e.g., Emily will touch a spider), while the standard exposure will use a first-person perspective (e.g., I will touch a spider). Before and after the exposure therapy session, this study will assess 1) Approach -indexed using both behavioral (ability to get physically closer to live spider, and video-derived motion analysis) and physiological (i.e., heart rate \[HR\], heart rate variability \[HRV\] and electrodermal activity \[EDA\]) metrics, collected during a validated behavioral approach test (BAT) (Bernstein and Nietzel, 1973; Borkovec et al., 1997; Ollendick et al., 2011) and 2) severity of specific phobia using validated self-report scales. During each of the 7 steps of exposure therapy, investigators will measure physical distance from fear stimuli used in exposure tasks, and collect continuous data to derive physiological (i.e., HR and HRV) and behavioral metrics of approach (i.e., video-derived motion analysis and audio-derived linguistic metrics) and ask participants to subjectively rate their distress. Data will be analyzed to assess whether SD augmentation of exposure therapy improves treatment outcomes in youth with specific phobia, as well as to establish objective, measurable metrics for assessing engagement with exposure tasks.