There are so many misconceptions about Obsessive-Compulsive Disorder. In particular, people frequently think it is about being neat, tidy, and organized. They often think it doesn’t affect children. Very importantly, people do not realize that OCD requires specialized treatment by someone trained to do a particular kind of Cognitive Behavior Therapy (CBT) know as Exposure with Response Prevention (ERP). In this interview by Alison Dotson, Nathalie Maragoni (who both has OCD and is training to be a therapist) beautifully describes what OCD can look like in a child, ways to educate the school, and resources for adults with OCD and for parents.
The 2nd annual OCD Southern California conference is in Irvine on Saturday, March 25th. It’s a wonderful opportunity to meet leading clinicians and researchers, get great information, and have the opportunity to interact with others who deal with Obsessive-Compulsive Disorder.
This year’s keynote speakers are Jonathan Grayson, Ph.D., of the Grayson L.A. Treatment Center for Anxiety & OCD, and Ethan Smith, National Spokesperson for the International OCD Foundation. For more information and to register, go to:
The music is pumping, the class is full, and the energy is palpable in the room. Fitness trainer and indoor cycling instructor Wendell Mitchell moves through the rows of students.
“Get comfortable being uncomfortable!” he calls over the music, and the students respond, each giving a little more than they thought they could a moment ago.
The anxiety therapist in me delights in what is happening here. He directs students to do what’s difficult – what’s outside their comfort zone – and they do it. Each knows on some level that the only way to get to where they want to be (weight loss, endurance, energized, etc.) means having to push themselves through some level of discomfort. They know that it won’t be given; it has to be earned. “No pain, no gain” is the familiar gym mantra.
“This is just like anxiety treatment,” I think to myself.
In anxiety treatment, the therapist instructs and encourages the patient to act outside of
their comfort zone, to do something different than they might already be choosing to do. By taking these steps forward, anxiety is something that one can learn to manage and to thrive with. Yet many people fear what treatment for anxiety will be like. Just the mention of standing up to your fears is enough to keep many away from the treatment that could open the door to a much better life.
What Does He Know?
I’m intrigued by how Wendell is able to get so much out of his students, and I wonder what it is that he knows that benefits his fitness students, and applies so well to anxiety sufferers. I sit down with him to talk one sunny day. It’s clear from the start that, in the nearly twenty years he has been in the fitness industry, he has developed a passion for changing lives. I wonder with him how he is able to inspire motivation in his students – and what nuggets I might take from this into my treatment of anxiety sufferers.
He is quick to point out that the motivation must come from each individual themselves, and not from any goal he might have for them.
“They need to find what their motivation is for being here,” he says, noting that he encourages students to think about why they are in class.
I quickly draw a parallel to anxiety treatment. A person seeking treatment must know their “Why?” Why are they in treatment? It is the job of therapist to instruct the patient in successful techniques and to nurture that inner motivation – that “Why?” – and keep it in sight throughout treatment. Without a “why,” there is no compelling reason to get better. In fitness, the motivation might be to live a healthier life. With anxiety, the motivation might be to be able to do things a person has been wanting to do, but has felt too afraid to try.
Wendell also explains to me that something happens when a person decides to push themselves, even just a little. There’s a recognition that they did something that they previously thought they could not – and that tends to trigger even more motivation.
“It’s empowerment,” he says. “Most people walk away feeling unstoppable.”
Again, I draw a parallel to anxiety treatment. When a patient does something that they previously thought they couldn’t, there is an incredible feeling of empowerment. And this empowerment tends to help propel a person forward. The memory of that success can be a great motivator.
With anxiety treatment, just as with fitness training, finding your “baby steps” is key. Rarely does a fitness student or anxiety patient start with the most difficult task. If you’ve never taken a 45 minute indoor cycling class before, you probably wouldn’t expect to be a top performer in class on your first day. And if you’ve never stood up to a particular fear before, you most likely wouldn’t expect to stand up to the scariest thing right off the bat.
“You need to figure out where their baby steps are,” says Wendell, when discussing taking the trip up the fitness ladder. Then you can “celebrate the little small victories.”
When it comes to anxiety treatment, the same is true. A person chooses the steps that feel manageable to them as they work their way toward conquering a fear. Each step is a cause for celebration.
Most people begin a fitness routine knowing it will be tough work. As Wendell likes to say, “this is a workout, not a cookout, folks.” Any patient I ask about getting fit or getting good at something that involves fitness (from cycling to hiking) can tell me that it is more than just showing up and going through the motions. It takes hard work, and if one does the work, they will see improvement, and what seemed difficult at first gets easier. The same is true for anxiety treatment. It takes hard work facing your fears, learning new ways of coping, and pushing through challenging exposures. Yet the payoff is seeing what seemed insurmountable before become more manageable – maybe even easy. And just like in fitness, you get to do it at your own pace. Pushing yourself harder means more progress; going a little slower means more measured progress.
The key is “being willing,” says Wendell when he talks of progress in fitness. A person has to be willing to push themselves toward a goal. If they do, they may find themselves somewhere unexpected.
“I didn’t think I could do it, but here I am. I’m not gonna like it, but I’m gonna do it again.”
With anxiety as it is with fitness, if you push yourself, practice, and repeat – willingly – you may find yourself soaring to places you never imagined. Get comfortable being uncomfortable.
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.
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.