Courage Clinician Guide Clinical Resource Toolkit
Courage Clinician Guide
CBT & ERP Protocol for Public Spaces and Agoraphobia
Evidence-Based
Clinical Rationale & Objectives
Public spaces present multi-sensory triggers that exacerbate agoraphobic fear and catastrophic cognitions (e.g., collapse, panic, social scrutiny). This guide aligns with Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) to systematically desensitize the nervous system, disrupt avoidance behavior, and reframe safety-related core beliefs.
Step-by-Step Exposure Ladder Formulation
Collaboratively outline 5 to 10 exposure scenarios. Ensure situations are specific, measurable, and highly relevant to the patient's real-world environment.
SUDS Range Subjective Experience Exposure Application Guidelines
0 - 30 Mild / Baseline Safe starting zones. Good for building foundational coping, grounding, and initial somatic awareness.
40 - 65 Moderate Distress The "Target Zone" for early-to-mid exposures. Evokes clear physical responses and anxiety. Perfect for cognitive restructuring practice.
70 - 100 Severe Distress Highest triggers (e.g., peak crowd times, no instant exit). Attempt only after patient demonstrates distress tolerance at moderate levels.
Core Cognitive Distortions to Target
Catastrophizing
Assuming panic will lead to catastrophic outcomes (e.g., "I will pass out," "I will have a heart attack," "I'll never escape").
Spotlight Effect
The irrational belief that everyone in public is closely watching, evaluating, and judging the patient's anxious symptoms.
Core Somatic Grounding Skills
Equip the patient with regulation techniques prior to high-level exposures. Emphasize that these are tools for tolerating distress, not escaping it.
Box Breathing (4-4-4-4): Regulates heart rate variability and counters physiological hyperarousal.5-4-3-2-1 Sensory Reset: Directs attention outward to disrupt internal loops of worry and hypervigilance.Progressive Muscle Release (PMR): Contrasts physical tension with conscious relaxation.
Agoraphobia & Public Spaces Clinical Series Page 1 of 2
Clinical Resource Toolkit
Exposure & Debrief Protocol
Intervention Delivery and De-escalation Strategies
ERP Focused
Targeting Subtle Safety Behaviors
Safety behaviors are actions patients take to prevent feared catastrophes. Over time, these reinforce the belief that the environment is inherently unsafe. Help patients identify and phase these out:
Common Safety Behaviors:
Sticking exclusively to walls/exits
Wearing dark sunglasses or hats to hide
Staring intensely at mobile devices
Clinging to support persons/objects
Over-planning exit routes before entering
Exposure Response Prevention (ERP):
Position themselves in central open aisles
Maintain normal open visual eye contact
Keep device stowed away in pocket/bag
Complete outings alone when ready on ladder
Embrace spontaneity in physical location
Guided Restructuring Scripts
Use these clinical prompts during exposure design or real-time check-ins to challenge core anxieties and encourage distress tolerance:
“Anxiety is a highly uncomfortable physical sensation, but it is not inherently dangerous. Your body is trying to protect you, but the alarm is simply too loud right now. Let's let the wave peak, stay right here, and observe as it naturally subsides.”
— Somatic Grounding Script
“What is the worst possible outcome you are predicting right now? What evidence do we have from previous panic episodes that this will occur? What would a compassionate friend tell you about your ability to cope with this discomfort?”
— Cognitive Restructuring Script
Post-Exposure Debrief Checklist
Validate Tolerability: Discuss the discrepancy between predicted disaster and actual outcome.
Track SUDS Peak: Note the highest SUDS level reached and how quickly it returned to baseline.
Review Safety Tactics: Evaluate if any hidden safety actions were used, planning to limit them next time.
Reinforce Mastery: Treat panic symptoms as opportunities to gather "courage capital" rather than failures.
Agoraphobia & Public Spaces Clinical Series Page 2 of 2
Step by Step Exposure Ladder Patient Toolkit
My Step-by-Step Exposure Ladder
Mapping your journey back to public spaces with courage and pacing
One Step at a Time
Patient Name:
Date:
My Core Exposure Goal:
How to construct your ladder: Work with your therapist to list public situations that make you anxious. Order them from your baseline comfort (bottom) to your most challenging target scenario (top). Use the SUDS Scale (0–100) to estimate your anxiety level for each activity before you try it.
The Exposure Steps
Write your specific activities below
Step 6 Peak
SUDS
Step 5 High
SUDS
Step 4 Mod+
SUDS
Step 3 Moderate
SUDS
Step 2 Mild-Mod
SUDS
Step 1 Baseline
SUDS
SUDS Cheat Sheet
70 - 100 Panic, body sensations
40 - 69 Uncomfortable, escape urge
20 - 39 Mild worry, manageable
0 - 19 Relaxed and safe
My Grounding Anchors
Pre-plan three sensory grounding skills, thoughts, or somatic anchors to stabilize yourself when climbing your ladder.
1. Physical Anchor (e.g. tactile focus):
2. Cognitive Reminder (e.g. "I can tolerate this"):
3. Regulation Action (e.g. box breathing):
Therapist/Coach Notes:
Patient Coping Series • Courage in the Crowd Worksheet 1
Outing Thought Record Worksheet Patient Toolkit
My Outing Thought Record
Notice, challenge, and reframe automatic worries during public exposures
CBT Integration
Patient Name:
Date:
Planned Outing Location/Activity:
1 The Situation & Anticipated Triggers Describe who is with you and what you expect to face
2 Identify the "Hot Thought" & Predicted Disaster What is your mind shouting?
E.g., "I will pass out and people will laugh at me."
Predict SUDS (0-100):
3 Evidence Trial: Testing the Hot Thought Be a scientist. Base answers only on hard facts.
Evidence FOR the Thought
E.g., "I feel dizzy."
Evidence AGAINST the Thought
E.g., "I have felt dizzy before and never fainted."
4 Construct a Balanced, Alternative Perspective Grounded Reality
Combine facts to form a realistic outlook: "I feel dizzy from panic, but my heart is pumping well and I will stay upright."
5 After-Exposure Reflection & Re-Rate Complete this after returning from your outing
Actual Peak SUDS (0-100):
New Anxiety Level (0-100):
What did you learn about your ability to tolerate distress?
Patient Coping Series • Courage in the Crowd Worksheet 2
Pocket Courage Journal Printable Pocket Tool
Pocket Courage Outing Cards
Real-time exposure tools that fit right in your pocket
Cut & Carry
Directions: Print this page on thick paper or cardstock. Cut along the horizontal and vertical dashed guides to create four independent 3.5×5" clinical pocket cards to keep in your wallet or pocket during exposures.
CARD 1 • GUIDANCE
Pocket Outing Companion
Quick reminders to ground your nervous system in public spaces.
The Core Reality
Physical anxiety is highly uncomfortable but 100% safe. It is an alarm with no fire. Stay present. Let it peak and pass.
Spotlight Buster
People are busy with their own lives. No one is watching or judging your internal symptoms. You blend in perfectly.
Somatic Anchoring
Press your feet firmly into the floor. Feel the support of the ground underneath you. Keep your vision wide and relaxed.
Courage in the Crowd My Outing Companion
CARD 2 • LOG
Exposure Outing Tracker 1
Write directly on this card during or immediately after your outing.
Date:
Location/Activity:
SUDS Tracker (0-100)
BEFORE
PEAK
AFTER
Somatic Responses Observed:
Courage in the Crowd Outing Tracker
CARD 3 • LOG
Exposure Outing Tracker 2
Use this for your second outing of the week to monitor patterns.
Date:
Location/Activity:
SUDS Tracker (0-100)
BEFORE
PEAK
AFTER
Somatic Responses Observed:
Courage in the Crowd Outing Tracker
CARD 4 • PANIC RESCUE
Emergency Anchor Protocol
If anxiety spikes over 70, initiate these steps immediately.
Step 1:
Box Breathing: Breathe in 4s, hold 4s, exhale 4s, hold 4s. Repeat this 4 times to physicalize calm.
Step 2:
5-4-3-2-1 Sensory Reset: Look around. Find 5 things you see, 4 you feel, 3 you hear, 2 you smell, 1 you taste.
Step 3:
Cope Statements: Say: "This is a wave of high adrenaline. It is temporary. I can ride it out."
Therapist/Emergency Contacts:
Courage in the Crowd Emergency Anchor Card
Patient Coping Series • Courage in the Crowd Worksheet 3
