I am preparing to head to the annual conference of the Anxiety and Depression Association of America (ADAA). I look forward to conferences like this one because they provide inspiration for the work I do and the opportunity to interact with the latest information and the great minds that are working on treatments for anxiety and depression. This year, I am fortunate to be able to present at the conference on a topic that is of great interest to me, since I work with a good number of children and teens: Engaging Parents in Children’s Anxiety Treatment. Because I think this is such an important subject, I’d like to share some of what I will share with the professionals at the conference here.
Through my practice, I’ve come to believe that parents are a very important ingredient when it comes to treating children who are struggling with anxiety disorders. Why? Well, first, it is generally parents who spend the greatest amount of time with their children and who are the “experts” on the child. As a clinician, I know that I have a great resource to tap into in the form of the parent. Who better to help me understand how this person spends their time, how they react to things, what they are sensitive to, etc.? Certainly I can often obtain a good deal of information from talking to the child or teen him or herself, but the outside perspective a parent provides is beyond valuable.
Next, working with anxiety requires a good deal of understanding on the part of the person with anxiety and their immediate support system. A big part of overcoming anxiety disorders is education. I spend a lot of time helping the people I work with to really understand how anxiety works and how to challenge it. The better educated someone is, the better they are able to make good choices for dealing with their anxiety. If a child or teen goes home to a parent who is well-educated in the ways of anxiety, that child stands a much better chance of finding success and support in defeating their anxiety.
Third, dealing with anxiety requires a lot of active work outside of session. Learning to defeat an anxiety disorder means a child or teen has to go home and practice, practice, practice. For that practice to be effective it has to be done regularly, with a good understanding of the purpose, and with a sound rationale. If I send a young person home to do practice that makes sense to no one but him or her, then the task is much more difficult. Without that support, a the chances the practice will happen decrease greatly, and treatment is going to progress much more slowly. If a parent who understands the work to be done is there to provide support and direction, then the work is much more likely to be done, and treatment is much more likely to move along.
Finally, once treatment ends, if a parent has participated in treatment, the child or teen is not alone in his or her knowledge and understanding of anxiety and its ways. Anxiety is a natural part of life and when it pops up a good plan is necessary to deal with any of the more difficult challenges it may present. When a parent has participated in treatment with a child, that child has an ally in identifying anxiety when it tries to disguise itself in the future. The parent might even recognize the signs and tricks of anxiety before the child or teen does. Parent and child can form a team to use the tools learned in treatment and put anxiety back in its place. They may even potentially prevent the need to return for treatment.
These are some of the reasons that I believe parents are an important part of the treatment team. Because of this, I try to let both parent and child know how important a player each is in the treatment process. In a future post, I will talk about some of the challenges parents face when they have a child who struggles with anxiety.
This week (October 14-20, 2013) is International OCD Awareness Week. Since promoting OCD awareness is a particular passion of mine, of course I’d like to seize on the opportunity to do a little educating. Just what is OCD? How does it present? Is it treatable?
Let’s start with a little background about how many people have OCD. It is generally thought that 1 in 100 adults has OCD and 1 in 200 children. That’s 4-5 children in the average elementary school, and about 20 in a medium-sized high school. Sadly, though, OCD is often under-recognized. The International OCD Foundation notes that it often takes between 14 and 17 years from the first onset of symptoms until a person gets access to effective treatment. Awareness of what OCD is can help to change that.
Simply put, OCD involves obsessions and compulsions. Obsessions are intrusive, recurring thoughts that are unwanted by the individual. They are associated with uncomfortable feelings and they interfere with important, valued activities. Compulsions are behaviors or mental actions a person engages in to try to feel better or to make the obsessions go away. Avoidance of things or situations that trigger obsessions can also be a compulsion. Compulsions only provide temporary relief. Common obsessions include fear of being contaminated, fear of causing harm to others, fear of losing control and fear of committing a moral offense. Common compulsions include excessive washing and cleaning, constant checking that nothing was done to harm others or that no mistake was made, mentally reviewing events, repeating movements or activities until they are “just right,” seeking reassurance and confessing.
OCD can be extremely agonizing for those suffering from it – and for those who care about them. It can result in lost productivity, lost opportunities and general misery. There are, however, effective treatments that exist. According to the International OCD Foundation, the key elements of treatment for most people with OCD are “one or more of the following: a properly trained therapist, Cognitive Behavior Therapy and medicine.” The Cognitive Behavior Therapy that has demonstrated the most effectiveness for OCD is called Exposure and Response Prevention. It basically involves confronting the thoughts, situations, etc. that make the person anxious and then making a choice not to engage in compulsions. While this may sound a little unnerving, the end effect is that the person learns to tolerate uncomfortable feelings and learns that they naturally lessen on their own.
A little while ago, I took a walk in a park that was along the cliffs of the Palos Verdes Peninsula. The day was clear and the view was beautiful. Except one thing kept popping up that disrupted my serenity. It was a sign that read, “DANGEROUS CONDITION. DO NOT CLIMB ON OR OVER RAILING. DON’T EVEN THINK ABOUT IT!”
“Gee, thanks,” I thought to myself. I looked to my companion. “You know, I wasn’t even thinking about climbing over the railing and now I can’t get it out of my head.”
Indeed, my companion was having images of climbing on or over the railing, as well. As if one warning weren’t enough, this same message was repeated on signs all along the cliff’s edge. They were far enough apart so that, just as the image began to fade, we were admonished once again to “DON’T EVEN THINK ABOUT IT!”
“That sign is an OCD sufferer’s nightmare,” I commented.
Indeed, one of the hallmarks of Obsessive-Compulsive Disorder (OCD) is intrusive thoughts and images. They are unwanted by the person, they cause distress and they won’t go away. What’s more, they play themselves over and over in the person’s head. It is these thoughts that make up the “Obsessive” part of OCD.
“Why Can’t You Just Stop Thinking About It?”
These are the words that many OCD sufferers hear from their well-meaning friends and loved ones – that is, if they are courageous enough to actually share that they are having unwanted, intrusive thoughts. In fact, most people with OCD will tell you that they already have tried to stop thinking about it. They may have put great effort into trying to make the offending thoughts and images go away. So often, though, it seems that the harder they try, the stronger the thoughts. How can this be?
Well, the sign I spoke of above is a good illustration of why it is difficult (if not impossible) to just stop thinking about something. Imagine it is you walking along the railing and the sign warns you, “DANGEROUS CONDITION. DO NOT CLIMB ON OR OVER RAILING. DON’T EVEN THINK ABOUT IT!” Now, try it. Don’t even think about climbing over the railing. Whatever you do, do not think about climbing on or over the railing. You’re not thinking about it, right? Do not think about climbing over or on the railing!
If you had images in your head of climbing on or over a railing, you are not alone. Our mind works so that when we struggle to try NOT to think about something, we tend to only think about it more. I will sometimes challenge people in my practice not to think about a white rabbit. Usually, they immediately begin to smile. That’s because they get it. That white rabbit popped into their head as soon as I said anything about it – and they realize the futility of trying to not think about it.
So, why can’t the person with OCD just stop thinking about an unwanted thought or image? Because our minds just do not work that way. It seems that we may do better if we simply do not try to fight away those unwanted thoughts, and instead go with them. We may just find that, when we do not fight with those thoughts, they begin to fade away on their own.
If someone in your life is strugging with OCD, remember that they cannot simply stop thinking about their intrusive thoughts and make them go away. There is, however, real help for managing these thoughts. Your support and understanding about how very difficult it is to get unwanted thoughts out of their head may be that person’s first step toward getting help and moving in a positive direction.
Fears – we all know someone who has them. Maybe we have them ourselves. Perhaps it’s a fear of spiders or snakes. Maybe it’s a fear of swimming or flying. We hear of fears like this so commonly that many of us don’t think twice when we hear about them. We may even accept them as a part of life that is just here to stay. But is that the case or can these fears be overcome and put to rest? If they can be overcome, how is that done?
Many people embrace their fears as a core part of themselves that is just never going to change – and they are vocal and public about their fears. Not long ago, as I was perusing Facebook, I noticed a friend had posted her fearful reaction to having found a spider at home. A long list of comments followed by folks agreeing with her fear or teasing her about it. Her responses made it apparent that the fear was here to stay – at least for now, and she had plenty of folks supporting her in keeping it that way.
Other folks live with their fears, but question if it always has to be this way. These people imagine life without their fear but are not sure if they could ever actually overcome it. An example of this is a mother who has a fear of swimming. It stems from a time as a child that she was pushed into a pool and panicked. She has never gone in a body of water again (well, except to shower, that is). She watches her two children play in the water at the beach and wishes she could join them in their fun. She also worries that she cannot help them if they get into trouble, so she always makes sure a lifeguard is around.
Of course there are other ways people think about their fears, but for the sake of simplicity, I’ll just focus on these here. So what about these two examples? Are they always stuck with their fears? Can they be overcome? Should they be overcome? Here’s my take on it. Unless something is a problem, it’s not a problem.
Have I confused you? What could I possibly mean by this? What I mean is that a fear is probably not a problem unless a person perceives it as causing a problem in their life. In the spider example, the woman is not really bothered by her fear. She can generally avoid spiders with little consequence to how she lives her life. When she does encounter the occasional arachnid, she has friends and family who are not afraid of them and who can take care of the problem. No big deal. Unless she has a big desire to challenge herself and get over the fear, she probably will choose, happily, to continue in this way.
The woman with the fear of swimming is a different situation. Her fear of getting into the water is keeping her from doing something she would really like to do – swim with her children and join in the fun. She also feels bad that she cannot help if her children get into a bad situation in the water and so she must wait for another swimming adult to be present before she can allow them to swim. She could go on and continue in this way. However, unlike the woman with the fear of spiders, she does perceive her fear of swimming to be a problem. She just doesn’t know what to do about it. She occasionally reaches out to others to ask how she can get over this. She might change it if she did know what to do.
If you are wondering at this point what creates a fear, simply put, fears can be created in all sorts of ways. They can develop if we experience a frightening event that involves the feared item or situation (e.g., falling into a swimming pool, not knowing how to swim and panicking). They can also develop if the feared item or situation is present at a traumatizing event (e.g., if we witness an accident while traveling on a freeway, we may develop a fear of freeways). It is also possible to develop a fear because someone we care about has the same fear (e.g., a mother is afraid of dogs and, through her own behavior, encourages the development of such a fear in her children).
But what does a person do about a fear? I’ve been asked this question many times. More important than understanding what created the fear, we must understand what maintains a fear. Generally speaking, fears are maintained by avoidance.
Imagine that a boy is scared by a dog one morning on his way to school. His heart races, his pulse pounds, and he breaks into a sweat as he runs away. Now, let’s say that afternoon, he has to pass by that dog again to get back home. Is he likely to walk confidently right by that house, or is it possible he might walk on the other side of the street, or on a different street altogether? If he chooses a path that keeps him away from the dog, he is likely to experience relief – dangerous situation averted. Whew! Now if he chooses each subsequent day to avoid the dog, his behavior is reinforced by the relief he experiences – and by the absence of the fear reaction. If he ever decides to walk by that dog again, it will probably be with great amounts of anxiety.
Now, let’s compound the situation and say that our young man sees a dog on another day that looks just like the original dog that frightened him. He starts to feel his heart pound and he can’t catch his breath. He doesn’t wait to find out if this is the same dog; instead, he bolts in the other direction. Once he perceives that he is “safe” he finds relief. Now, he starts to avoid the place he just encountered this dog and avoids any dog that looks like this one (or perhaps he avoids all dogs of this size, or any dogs at all).
The point is, all this avoiding the situation helps to reinforce his fear. If he avoids the situation, then he can avoid feeling any fear. Perhaps to him it is a small price to pay. But he is missing out on the opportunity to be able to move about the world more freely. What he has not had to chance to learn is that if he had never avoided the original situation in the first place, his body would have naturally adjusted and his fear would have reduced greatly (if not completely).
Our bodies are amazingly adaptive. They have the ability to adjust to a myriad of situations. Just think about the first time you tried a new exercise. The next day you were aching and could barely move that body part. The next time you did the exercise you didn’t ache as much and there quickly came a time that you didn’t ache at all. You wondered if you were still doing the exercise right. Or consider a cold swimming pool. When you first get in, it feels like a shock to your system. You wonder what you are doing in there. If you stay in for a little while an amazing thing happens. You adjust and the water feels fine. In both of these examples the situation did not change. The exercise is not any different and the water temperature did not change. Your body adjusted because you gave it the time to do what it does naturally – adapt.
The same is true with a fear. If we continually avoid a feared situation, we maintain the fear; we never give our body time to adjust. If we face the fear, at first we will feel anxious, scared – maybe terrified. If we stick with it, an amazing thing begins to happen. The frightening thing or situation begins to feel less scary. If we keep facing that fear over and over again, it loses its power over us.
Am I saying that someone with a fear of spiders should immerse themselves in a pit of the creatures, or that someone with a fear of swimming should jump into a swimming pool? No, I’m not. There is some skill to beginning to chip away at a longstanding fear and what works for any person is as individual as they are. Some people know intuitively what they can tolerate and their instincts will guide them about what to choose. Others will find guidance in a book that addresses the issue, while still others find that the support of a professional is best for them.
Some people will live happily without ever confronting a fear because that fear barely impacts on their lives or happiness. For those whose fears are impacting them in some way that creates dissatisfaction or unhappiness, there is hope to get past them. The point for these people is to begin to challenge the avoidance that keeps them stuck in their fear -to feel empowered rather than powerless. In this way, those pesky “little” fears can be put where they belong – to rest at last.
Sometimes, I wish my head could keep up with my conversations – that I had the right response at the right moment. A little while ago someone who rarely asks me about my work asked how my practice was going. I responded by mentioning how many young boys and girls with some very big fears had recently been brought by their parents for treatment. Some, I noted, were having full blown panic attacks.
Now I was fairly certain my conversation partner would say something like, “Wow. What do you do in situations like that?” or perhaps, “It’s good that they are getting help now.” Instead, what I got was, “Parents can be so over-reactive. They take a normal part of child development and turn it into a problem. If they would just leave it alone, it would pass.”
This is where my spinning head could not keep up. In part, my professional ego was a little bruised (“Don’t you think I can tell the difference between a child who’s going through a normal phase and one who is truly suffering?” ). At the same time I was feeling a little defensive about the parents who had the courage and the sensitivity to bring their child for a consultation. Frankly, I think it takes a lot of guts to admit that something is going on with your child and to reach out for help.
Yes, sometimes parents do overreact about something that is a childhood phase. They love their kids. They want to see them happy and healthy. It’s part of what they do. At the same time, too often children’s and teens’ emotional issues are overlooked or not attended to. According to the Child Mind Institute[i], more than 15 million children in the U.S. have diagnosable mental health or learning disorders, yet less than half of them will actually get help. In addition, the National Institute of Mental Health (NIMH)[ii] notes that the results of a large national survey indicate that approximately 8 percent of teens have an anxiety disorder. Their symptoms appeared around age 6. However, less than one-fifth of these teens ever received mental health care.
What’s sad and concerning about this is the loss of potential and the unnecessary suffering – for both parents and kids. There are effective treatments available that can help get these kids back on track and the whole family functioning better. But how does a parent know when something is normal childhood development and when it is time to seek help?
Anxiety is a normal part of life for us all. For a child, there are certain worries and fears we can expect at different ages. For example, very young children may be afraid of strangers, the dark, imaginary monsters, costumes, being separated from parents and getting hurt. Older children may worry about school performance or making friends. If we provide reassurance and are supportive as children learn to deal with these things, in most cases they will eventually resolve. When a fear or worry persists, creates great distress for the child and interferes with the child’s functioning at home, school or with friends it has crossed over to becoming a problem. This is when it is time to seek help.
But when you seek help aren’t you just pandering to the child’s fears and making them an unnecessary focus? Well, the truth is that when adult anxiety sufferers are asked about the history of their symptoms, a high percentage of them actually have symptoms dating back to childhood. Their symptoms did not go away . So treating children for anxiety may not only help the child from spending needless time suffering, but may help prevent anxiety disorders in adults as well.
Getting back to my conversation, if my head had been working at the proper speed, I would have said something along these lines:
“At times, you are correct, we as parents do overreact, but we also frequently under-react. Actually what’s going on with these kids isn’t part of normal child development and these parents aren’t over-reactive at all. I admire them. They recognized that their children were suffering and that this was not going to go away on its own. They were forward thinking enough to reach out and get help. Hopefully we will be able to prevent a lot of suffering now and in the future.”
I can’t make time stand still and give a well-composed answer. For now, at least I am on the record. Children with anxiety disorders deserve their suffering to be recognized and they deserve the opportunity to get better. Bravo to the parents who have the courage to reach out.
As I write what is to be the first blog entry of my new site, I find myself compelled to share a story about an ending. Not too long ago a young patient who had struggled with anxiety came in for session full of energy, family in tow. I sat ready to set an agenda for the day’s session. Instead, my patient told me with a smile to sit back, watch and listen. So all of us sat back in my office and were treated to a 20 minute, one-person show (complete with props) about how to defeat the “Worry Monster.”
In case you’re wondering, the Worry Monster is a generic term some therapists use to help younger patients conceptualize their anxiety. We talk about anxiety or worry like it’s a bully who keeps coming by to boss you around. Defeating the Worry Monster means learning how to boss back and put him (or her) into his place. Many of my young patients quickly latch onto this concept and delight in doing some bossing around of their own.
So…back to the session. This play was so thorough, so complete in its understanding of anxiety, its description of how to overcome it and the breadth of tools it employed to be victorious that I was completely giddy. I immediately congratulated my patient, and the whole family, on becoming so well informed and on understanding how to implement that knowledge. What I knew, upon seeing this play, was that we were at the beginning of the end of treatment.
This was not the first time that I’ve been schooled by a patient in the ways of dealing with anxiety. Hopefully, it will not be the last. What it represents for me is what treatment is all about – getting patients to the point where they don’t need to be seeing me regularly anymore. No matter what goal treatment starts with, there is one underlying goal that is common among the people I treat – to get their situation to the point where they intrinsically know how to respond to potential struggles and they no longer need me in order to cope well. When I am working with anxiety, parents and patients often ask me how we will know when it is time to stop treatment. One of the things I tell them is: “We will know it’s time to stop treatment when you (or your child) start coming in and telling me how to intervene, and you actually are able to go ahead and successfully use the interventions you come up with.”
When I work with anxiety, a good deal of what I do is to teach. I work to educate children and adults about what anxiety is, what maintains it and what puts it in its place and makes it manageable. I find that when people have a way to understand their struggles, a frame to put it in, that treatment makes much more sense. Even my youngest patients can understand anxiety when I put it in their terms. When they understand, they feel more powerful…and they delight in taking charge of their lives.
When my young patient arrived for treatment and taught ME how to deal with anxiety, I knew we were at the beginning of the end of treatment. I’m not sure who was more delighted at this prospect – me or patient and family. We had strived together to get to this point. The payoff was a child who had emerged from fear, who felt powerful instead of powerless and who felt ready to take on what anxiety might dispatch. I think that this experience, and others like it, is what I bring into the beginning of treatment with each new patient. I bring the belief that with each new beginning, each first step into treatment for people who are struggling with fear and worry, there is hope for a more empowered ending. And it is my honor to be told to sit back, watch and listen as they move forward to live their lives.