Overview of Anxiety

Josh’s experience is illustrative of many anxiety disorders with onset during adolescence. Anxiety disorders have been identified as the most prevalent childhood and adolescent mental health disorder (Allen et al., 2013; Cartwright-Hatton et al., 2006), and anxiety disorders also seem to be persistent through adulthood if criteria for an anxiety disorder is met during childhood (Dias & Campos, 2016).

It is important to distinguish clinical anxiety from developmentally normative childhood fears. Common childhood fears include being alone, separation from trusted others, the dark, imagined monsters, and unexplained loud noises. Developmental sequences of fears suggest that fears about separation are most common among young children (Weems & Costa, 2005). Fears related to death and danger become more prevalent in middle childhood, and fears about how others see us, accompanied by anxieties in social or performance situations, are most pervasive during adolescence (Weems & Costa, 2005). The avoidance and/or distress associated with objects, situations, events, and memories that trigger anxiety vary widely across the seven anxiety disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5; American Psychiatric Association, 2013).

Transient fear or anxiety is often stress-induced and short-lasting. Clinical anxiety is excessive and persistent (e.g., symptoms must last longer than six months for all diagnoses with the exception of separation anxiety and selective mutism) and developmentally atypical. Some individuals are able to state that their experience of anxiety is excessive, whereas others struggle to make this distinction. In these cases, clinicians take cultural and contextual factors into account to determine if anxiety is excessive. Anxiety that is diagnosed in childhood often persists into adulthood if left untreated and puts individuals at increased risk for negative outcomes such as impairments in family and occupational functioning, substance use, educational underachievement, reduced life satisfaction, and suicide (e.g., Swan & Kendall, 2016; Wolk, Kendall, & Beidas, 2015).

Prevalence of Anxiety Disorders in Youth

Worldwide data shows a prevalence rate of 6.5% (Polanczyk et al., 2015), national data in the US showing a prevalence rate of 7.1% to 12.3% (Costello et al., 2005; Ghandour et al., 2019). Approximately 15% to 30% of children will be diagnosed with anxiety at some point in their childhood (Bittner et al., 2007; Woodward & Fergusson, 2001). Anxiety disorders are not as often diagnosed as other disorders such as disruptive behavior disorders, as disruptive behavior disorders are more likely to be brought to adults’ attention during childhood years (CDC, 2020).

Anxiety occurs frequently with other behavioral and emotional disorders (Kendall et al., 2001). Palitz and colleagues (2019) outline the most common comorbid diagnoses among youth with anxiety as being a) other anxiety disorders (Kendall et al., 2001), b) obsessive-compulsive disorder (OCD; Carter et al., 2004; Kendall et al., 2010) and c) depressive disorders (Costello et al., 2003; Cummings et al., 2014). Disruptive behavior disorders such as Attention Deficit/Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD) are also common comorbid diagnoses (Palitz et al., 2019). The presence of comorbidity can influence treatment if the other condition interferes with treatment, just like treating other disorders with comorbidity (Kendall et al., 2001; Palitz et al., 2019). As mentioned in our interview, Margaret Crane suggested that if Oppositional Defiant Disorder is present, a clinician may need to consider more behavioral reinforcement strategies in session or in doing exposure work at home. If depression is present, the behavior activation could be a part of the intervention.

How Anxiety Disorders Develop in Children

The development of child anxiety stems from the interactions of many factors. A behaviorally inhibited toddler is an aspect of temperament that can create vulnerability for anxiety (Rapee, 2014). In terms of psychological processes, children that have attention bias towards threat related stimuli can be predictive of later anxiety, and the threat pattern can enforce a cycle of fear appraisal and avoidance (Mayer, 2017). Parental anxiety disorders can also be predictive of child anxiety, with the heritability coming from genetic or behavioral influences such as anxiety modeling (i.e., children see their parents as anxious and learn these anxious behaviors) (Havinga et al., 2017). Parenting styles that are overly accommodating can additionally serve as this social modeling of anxious behavior (Dadds, 2017). Social and environmental factors will be discussed more in the next section.

Developmental Systems Considerations for Anxiety Disorders in Youth

The case of Josh presents a good example for the discussion of developmental systems considerations. Josh appears to have had an anxious temperament during childhood, which increased significantly during middle and high school. The principles of developmental systems can be used to consider the reasons that increases in social anxiety did not lead to Josh’s enrollment in therapy. Josh’s parents might have normalized his experience of excessive and persistent anxiety as “just the way Josh is.” Both Josh and his parents may have believed that Josh would “grow out of it.” Parents who believe their children will grow out of anxiety may find themselves engaging in accommodating behaviors to help children manage anxiety “in the meantime.” Accommodation refers to the actions that family members take to alleviate a child’s symptoms and distress (Kagan et al., 2017). Accommodation can take the form of excessive reassurance, allowing the child to avoid new or challenging situations, or trying to problem-solve for the child. Accommodation is associated with negative sequelae for family members and results in the maintenance of anxiety (Kagan et al., 2017). Parents are instead encouraged to not give in to the child’s anxiety by letting the child avoid the anxiety-provoking stimulus. Parents should coach their child to use distress tolerance skills, and over time, the child will learn that their anxiety is not dangerous or scary and that they can self-regulate.

One of the most prominent systems in a child’s life is the school system. In the school setting, the term “accommodation” can refer to school-based supports that aim to increase access to general curricula for students with a range of disabilities. Students who inform school personnel about their anxiety related distress are more likely to access treatment (Colognori et al., 2012), showing how schools are vitally important to get youth the interventions they need. School-based mental health programs show evidence of impact on youth emotional challenges (Rones et al., 2000). School-based accommodations related to emotional problems are legally outlined in documents such as Individualized Education Programs (IEP) and 504 plans (IDEA, 2004; Sulkowski et al., 2012). School staff report implementing a variety of school-based accommodations, including those that are approach-based, and thus most likely to helpfully address anxiety (Conroy et al., 2020).

Accommodations can have unintended results, too. Unhelpful accommodation (accommodation that is avoidance-based) is also common in schools. For example, if Josh was nervous to give a presentation in front of the class, a teacher might have allowed him to give the presentation only to him/her, thereby maintaining the anxiety. Accommodations can be helpful if they are specific and short-term. It may have been helpful for Josh’s teacher to allow him to first give the presentation to just him/her, then to a small group of students, and then to the entire class. School can also be the source of stressors that go unreported by youth, such as bullying, which may lead to anxiety. Was Josh labeled as oppositional and defiant, causing teachers to miss the connection between undesirable behaviors and anxiety? Josh’s academic achievement improved at the small, private school; however, it is unclear what about this environment was helpful. Were unreported stressors at the public school not present at the private school? Did Josh receive more individualized attention and accommodation, either unhelpful or helpful, at the small private school?

The developmental systems perspective also highlights the importance of the mind-body connection. This connection also shows the importance of how development and ecology intersect; the physical body develops across time in an environment. Like an example of a baby “relearning” how to walk each day because of their growing body, youth will have to “relearn” or retrain their emotional muscles to adapt to the emotional and physical changes related to their development.  Many individuals experience anxiety physiologically, experiencing somatic symptoms such as racing heart, sweating, and shortness of breath. For many individuals, anxious thoughts can lead to somatic symptoms, which can then lead to more anxious thoughts. Of note, some people report only experiencing somatic symptoms of anxiety whereas others report experiencing only cognitive worries.

Experiences of Anxiety Across Race and Ethnicity. Cross-sectional research has shown mixed findings when investigating racial variations in anxiety presentations, with some samples showing higher symptom levels for African American youth (Latzman et al., 2011), and other samples showing no differences between racial groups (Wren et al., 2007). In a separate sample, Kendall and colleagues (2010) found that Caucasian youth were more likely to meet diagnostic criteria for generalized anxiety disorder only, whereas by comparison, non-Caucasian youth were more likely to meet diagnostic criteria for both separation anxiety disorder and specific phobia in comparison. This study though, did not delineate different groups within non-Caucasian youth. This study was drawn from The Child/Adolescent Anxiety Multimodal Study (CAMS), which sought to understand the relative or combined efficacy of cognitive behavioral therapy and selective serotonin-reuptake inhibitors for anxiety disorders in children (Walkup et al., 2008).

Data from CAMS revealed similarities in baseline clinical characteristics in African American and Caucasian youth with anxiety disorders (Gordon-Hollingsworth et al., 2015) based on their scores on the Pediatric Anxiety Rating Scale (PARS, 2002) and the Screen for Child Anxiety Related Emotional Disorders, Parent & Child Forms (SCARED-C/P; Birmaher et al., 1997). Despite similar baseline measurements, African American youth attended fewer therapy sessions than their Caucasian counterparts, which is significant because higher treatment engagement predicted better treatment outcomes (Gordon-Hollingsworth et al., 2015). Lower treatment engagement, a process variable, can increase the risk for poorer treatment outcomes for African American youth, highlighting the importance of identifying the best ways to engage patients (Gordon-Hollingsworth et al., 2015). Importantly, treatment response did not differ as a function of race (Gordon-Hollingsworth et al., 2015). These findings highlight the efficacy of anxiety treatment in youth from non-Caucasian backgrounds. Findings also highlight the importance of accurately diagnosing and treating clinical anxiety in all youth.

Experiences of Anxiety in LGBTQ+ Youth. In a review of the prevalence of mental health problems among LGBTQ+ youth, Russel and Fish (2016) found that 25% of LGBTQ+ youth meet diagnostic criteria for an anxiety disorder. LGBTQ+ youth report higher levels of anxiety symptoms compared to heterosexual youth (Russel & Fish, 2016). Youth who experience or fear family rejection because of their sexual orientation are at a higher risk for anxiety (Russell & Fish, 2016). In the lens of the minority-stress model, LGBTQ+ youth may not have skills to cope with this anxiety (Russell & Fish, 2016) because it is an experience unique to them. This can limit opportunities for social learning of skills and/or limit their ability to use such skills. The adaptation of EBPs for anxiety and LGBTQ+ youth is rather limited (Busa et al., 2018), and guidelines about affirmative care show that this care approach can impact rates of improvement with clinical symptoms in regard to depression and suicidality but not anxiety (Kattari et al., 2016).

Assessment of Anxiety Disorders in Children and Adolescents

There are many anxiety disorder diagnoses. Though treatment for anxiety disorders is largely similar across diagnosis, identifying a specific diagnosis can help clinicians tailor their interventions. Common anxiety disorder diagnoses include: Separation Anxiety Disorder, Generalized Anxiety Disorder, Social Anxiety Disorder, Specific Phobias, Panic Disorder, and Agoraphobia. Anxiety symptoms are considered clinically significant if they result in functional impairment for youth or their families (e.g., several weeks of missed school, parents being unable to leave the house without the child, failing grades, inability to form or sustain friendships) (APA, 2013; SAMHSA, 2016). For detailed diagnostic criteria related to children, consult the DSM-5 Changes: Implications for Child Serious Emotional Disturbance resource (SAMHSA, 2016).

Approximately 2% of youth meet diagnostic criteria for Generalized Anxiety Disorder (GAD; Merikangas et al., 2010). GAD is characterized by persistent and uncontrollable worry about a variety of topics (e.g., health, family issues, school, safety, minor matters, the future) (American Psychiatric Association, 2013), and it has historically been identified as one of the most poorly understood (Rowa et al., 2013) and difficult to treat anxiety disorders (Salters-Pedneault et al., 2006). However, research has indicated that exposure-based cognitive-behavioral therapy (CBT) is efficacious in the treatment of GAD in youth (Kendall et al., 2008; Ladouceur et al., 2000; Read et al., 2013; Walkup et al., 2008).

Separation Anxiety Disorder (SAD) is distinguished by anxiety, fear, or distress in a child when they are away from home or a caregiver (APA, 2013; SAMHSA, 2016). The excessiveness of the anxiety and fear must be understood in the context of a child’s age and development. For example, it is more developmentally appropriate for a toddler to be afraid of being away from home than it is for a teenager to struggle with the same fears. An elementary-aged child having tantrums every morning before school would be considered developmentally inappropriate (Palitz et al., 2019). Separation anxiety can involve panic attacks and noticeable uneasiness.

Social Anxiety Disorder centers on the fear of social situations in which someone may experience or perceive scrutiny from others (APA, 2013; SAMHSA, 2016). Social anxiety may manifest as “performance anxiety” for some youth. Children with social anxiety may experience distress in the presence of both peers and adults. (APA, 2013; SAMHSA, 2016). A youth with social anxiety may experience debilitating difficulty with activities that involve public speaking, such as giving class presentations.

Panic Disorder has two distinct characteristics: recurrent panic attacks and fear or worry related to having future panic attacks (APA, 2013; SAMHSA, 2016). Panic attacks are typically short, intense bursts of fear (lasting no more than 10 minutes) that are accompanied by physical symptoms like difficulty breathing and tingling. Panic attacks can occur in response to a known stimulus (colloquially, a “trigger”) or “out of the blue,” with no identifiable stimulus. Panic attacks themselves may or may not significantly disrupt the youth’s life; however, fear about having a future panic attack can lead to debilitating levels of avoidance.

Assessment Tools for Anxiety Disorders

Interview Questions for Client, Family Member, Teacher. Many of the most helpful interview questions for clients and their family members are associated with semi-structured diagnostic interviews, one of which we discuss below (“Measurement Tools and Rating Scales”). It is helpful to obtain as much specificity as possible around the client’s anxiety symptoms and triggers. For example, an interviewer may benefit from asking Josh what he is worried will happen at work. Is he nervous that he will say something embarrassing that will cause his coworkers to view him negatively? Or is he worried that increased somatic symptoms will lead to a panic attack? Gaining a clear sense of the client’s anxiety profile will promote accurate diagnosis and thus treatment success. Teachers and other school staff who spend a significant amount of time with youth are also a helpful resource when assessing anxiety. School staff may have more information about school-related anxiety than clients’ parents and are able to provide greater context about the school environment and the youth’s behavior. For example, an interviewer may benefit from asking school staff what they have noticed about Josh’s interactions with other students both during and outside of class over the past several months. Does Josh visit the nurse’s office often? Does he make complaints about somatic symptoms? Have they noticed avoidance in addition to Josh’s cutting class?

Observation in Naturalistic Settings. Where possible, it may be helpful for clinicians to observe youth in anxiety-provoking settings (e.g., Social Studies class, recess, sports practice, cafe). This may be particularly useful when working with youth who have difficulty articulating their anxiety triggers and symptoms. When observing, clinicians may attend to youths’ verbal expression, facial expression, and body language. Clinicians may also benefit from observing youth in at least one non-anxiety provoking environment. For example, it may be helpful to observe Josh spending time with his friend, as well as with other students with whom he is not close.

Measurement Tools and Rating Scales. The Anxiety Disorders Interview Schedule for DSM-5, Version 5 (ADIS-5-C/P; Albano & Silverman, 2016) is a semi-structured diagnostic interview that assesses youth psychopathology based on DSM-5 criteria. Youth and their parents provide separate ratings of impairment to diagnosticians. A diagnosis is considered present if either a youth or parent report meets criteria, and the diagnostician assigns a clinical severity rating (CSR) of 4 or greater on an 8-point scale. The ADIS can only be used by diagnosticians trained in its administration. The interview for each individual can take 2-4 hours. There is also cost associated with ADIS administration materials. For clinicians who do not have access to or training in the administration of the ADIS, there are various freely available measures that can be used to assess anxiety. The Screen for Child Anxiety Related Disorders (SCARED; Birmahauer et al., 1999) is a 41-item measure that examines five factors of anxiety (panic, generalized anxiety, separation anxiety). Multiple questions that have similar constructs help to ensure a valid score. The Revised Children’s Anxiety and Depression Scale (RCADS; Chorpita et al., 2000) and subscale Revised Children’s Anxiety and Depression Scale and Subscales measure depression, anxiety, and OCD. Both a short-form version (25-item; Enesitani et al., 2012) and a long-form version (original, 47-item; Chorpita et al., 2000) of the RCADS are available. Both the SCARED and RCADS have a supplemental Microsoft Excel version that makes scoring easy, saving valuable clinician time and bandwidth. Anxiety can have a variety of presentations in childhood. Valid assessment tools can help to provide diagnostic clarity and inform treatment.

Intervention

The CAMS study examined the efficacy of three anxiety treatments in youth: 1) CBT alone, 2) selective serotonin-reuptake inhibitors (SSRIs), and 3) CBT and SSRIs combined (Walkup et al., 2008). The study found that both CBT and SSRIs alone were efficacious, with a combination of the two producing the best results (Walkup et al., 2008). CBT programs such as Coping Cat and the teen counterpart, C.A.T. Project, are considered the gold-standard for youth anxiety treatment (Kendall & Hedtke, 2006). The computer-assisted version, Camp Cope-A-Lot, has been identified as an intervention tool that can be implemented in the school setting (Khanna & Kendall, 2008). Recent systematic review and meta-analysis confirms previous findings around the efficacy of CBT based programs and SSRIs in the prevention and treatment of child anxiety disorders (Schwartz et al., 2019)

Through the Coping Cat program, youth learn to manage anxiety using the FEAR plan: Feeling frightened, Expecting bad things to happen, Actions and attitudes that can help, and Results and rewards (Kendall & Hedtke, 2006; Palitz et al., 2019). Coping Cat teaches the FEAR plan through its two core components: psychoeducation/skill building and exposure to feared stimuli/situations (Kendall & Hedtke, 2006a, 2006b). Psychoeducation focuses on helping youth understand their physiological and cognitive experience of anxiety as well as the cycle of avoidance. Youth who are not enrolled in Coping Cat are still likely to benefit from psychoeducation about anxiety. Trails to Wellness, a CBT program for schools developed through folks at the University of Michigan, provides open-access handouts about how to approach psychoeducation about anxiety. In the vignette at the beginning of this chapter, we met Josh, who was experiencing high levels of somatic symptoms and was calling out of work frequently. Psychoeducation for Josh might include identification of his somatic symptoms and explanation of the avoidance cycle (i.e., worry at and about work will increase if he keeps calling out).

Skill-building revolves around developing internal and external coping skills. Positive self-talk statements and thought interruption techniques can help disrupt the anxiety cycle, and identifying automatic negative thoughts can be the first step to developing coping thoughts. It will likely be helpful to help Josh to identify the source and content of his automatic thoughts (e.g., worry about a negative work scenario repeating, “all or nothing” thinking, perfectionism). External coping skills can involve self-soothing activities, such as, listening to music, going on a walk, or watching funny YouTube videos. Josh may also find relaxation strategies such as paced breathing useful to cope with anxiety.

Exposure involves the hierarchical construction of anxiety triggers in an effort to work towards systematic desensitization of the fear stimuli (Davis et al., 2020). In CBT protocols such as Coping Cat, clinicians help youth to build a hierarchy of feared situations to be completed from least to most anxiety-provoking. A fear hierarchy should be collaborative, with the clinician working with both youth and the parent to get input about what situations to include in the hierarchy and how to rank them. It is important to be as specific as possible when placing situations on a fear hierarchy (Davis et al., 2020). Understanding the core fear behind the feared situation or stimulus is critical. For example, if Josh is afraid to answer the phone, the clinician can help him determine if he is afraid that he will say “the wrong thing,” anxiety about how his voice sounds on the phone, or something else entirely. Exposure can be an iterative process as well. Sometimes, the clinician may find that they must sometimes push the child to get out of their comfort zone, and other times, they may need to scale the parameters of an exposure back if it proves too difficult. It can be helpful to talk to youth about exposure as a way of “building your brave muscles” or beginning a new lifestyle of facing their fears. To learn more about the research and lab behind Coping Cat, see http://childanxiety.org/wps/parent-resources/information-and-resources/. Clinician materials can be found at https://www.workbookpublishing.com/.

School staff can be a helpful resource both when building a fear hierarchy and completing exposures. As discussed above, school staff often have context, experiences, and observations of clients that neither parents nor clinicians have. Thus, they may contribute meaningfully to fear hierarchy building. School staff will also be able to guide clinicians in understanding what exposures can and cannot be facilitated by the school. Some exposures may require the involvement of school staff (e.g., having a teacher call on a student in class). Coordination with school staff is also a helpful way to gather information about the success of between-session exposures.

The clinician decided that Josh had a fear of being judged by coworkers who could be watching him. So in session, the clinician walked down the clinic hallway and had Josh purposely trip in eyesight of another clinician. “I didn’t want to do it, and afterwards, I wanted to just run into the bathroom, I felt so embarrassed. But my clinician coached me through relaxing myself and we walked back to their office to cool down.” Over time, the clinician was able to build up to social exposure in more public places for Josh to work on, for instance, bringing the wrong item to the supermarket checkout so that he would need a cashier to help him end the transaction and go find the right item. “I know what I was doing, and I felt like an idiot. Afterwards, I realized no one knows what I’m thinking, they can’t read my thoughts, and I can’t read their thoughts. The cashier was actually pretty nice.” Over time, Josh started calling out less and less, and he stopped checking to see the manager’s schedule. He was on his way to being back in the driver’s seat with his anxiety.

Clinical Dialogues: Anxiety Disorders in Children and Adolescents with Leslie Norris and Margaret Crane

Sean E. Snyder, LCSW: We have two clinician-scholars from Temple University’s Child and Adolescent Anxiety Disorders Clinic for today’s interview, and this interview will provide us a unique window into a university clinic. Readers, pay attention to the core elements of what Margaret and Lesley share to adapt to your own clinic experience. Let’s get started.

With engagement, we frame it as the multidimensional aspects of commitment to treatment. When working with kids and anxiety, one of the hallmark features of these types of problems or disorders is avoidance, which is really the exact opposite of engagement! Avoidance behavior sometimes gives the child short-term relief. So, knowing that, before they even get in, you’re going to be working with an avoidant child or avoidant family. So, how do you join with families right in those first few sessions that are seeking treatment, knowing that avoidance is in the background.

Lesley Norris, MA: This question just made me really think about how hard it is. The things that we ask kids to do in therapy are basically taking their one coping skill that they rely on, avoidance, and then asking them to stop doing that thing that helps them get by. And that’s really scary. And I never want to lose sight of that. It really should come as no surprise to us as a result of that, but sometimes kids might come to our office, not feeling super excited to be there. They might be taken here by their parents. And as a result, I think that the first session is critical in terms of joining with the family. And I think what’s interesting about the Coping Cat protocol is that we actually do a surprisingly small amount of talk about the child’s anxiety when we first meet them. We definitely take time to introduce what to expect in therapy, but the majority of the session is playing get-to-know-you games where we’re getting to know the kids separate from their worries. Like, we know that you feel worried, but who are you as a whole person? And then also giving them a chance to get to know us as people, too. And I think that’s really important.

Researchers show that talking about anxiety too fast can lead to drop out. So, I think you don’t want to skip that step of getting to know one another. And I think, again, during that first session, we really introduce the idea that therapy is a team approach. So, this is not going to be a thing where you come for 15 minutes, and we “fix your child.” We’re all going to work together, and I will say things like, “I have a lot of expertise about what’s helped other kids, but kid, you know yourself better than anybody else. And Mom, you know your kid, better than anybody else. So, we’re all going to work together on this team to fight against this worry monster.” So, I think a lot of that happens in the first session.

Margaret Crane, MA (she, her): And then just to piggyback off of that, beyond the first session, especially in Coping Cat, we don’t actually get into exposure until session nine, and there’s certainly some debate about whether that’s too long. That said, though, it does mean that there’s a lot of time where kids are learning new coping skills. As Lesley said, right now avoidance is one of the main skills they are using. And during the first half of Coping Cat, they’re learning new skills, so that when they approach anxiety-provoking situations, I have those skills to offer them, to put it into practice.

Snyder: Earlier, Lesley, I heard you mentioned the term “worry monster.” Do you label that as an externalizing technique? Could you talk further about terms you use with anxiety and kids?

Norris: Yeah, I think there are a lot of individual differences across therapists in our lab with how frequently we’re using that externalizing language, but I love it. Mostly because I really like to personalize the manual as much as possible. And it’s a fun activity for me and the kid to come up with a name. So, we can use “anxiety monster,” although I often want it to be a little bit less scary and maybe something funnier. Kids have come up with terms like “anxiety ninja,” or like “worried dinosaur,” stuff like that. And it makes it seem just like less of this really big amorphous thing that’s taking over their lives and more like something we can all fight against.

Crane: And then even teens and adults sometimes like the term “worry monster,” but I had a teen who named her anxiety “Fred” for whatever reason. I don’t know if she knew Fred or whatever. But like Lesley was saying, it was personalized to, “What does it feel like your anxiety’s name might be?” And then we can really say, “Okay, am I talking to you, or am I talking to Fred?” And so, I think that can also be a helpful way to have clients see is this me who’s saying, “I don’t want to do this,” or is this the anxiety, saying, “I want to avoid this.”

Snyder: Great. And that’s the joy of working with kids, they can make you laugh. What they come up with and therapy can be fun. So, I mean, I’m thinking that from the child’s side, avoidance is their go-to strategy. It works in the short term, as we know, but in the long term, it doesn’t really work out for them. So, shifting gears is thinking about the primary thing, where the parents’ role is usually reassurance-giving. Kids will engage in reassurance-seeking from caregivers; the caregiver’s natural response is to attend because that’s just how we’re wired as parents. So, what’s it like, then, to provide education to parents about not necessarily giving in to reassurance-seeking where it feels like it’s, again, counterintuitive to what’s the natural drive for parents?

Crane: I think one thing I do is first acknowledge that it’s not very natural. It doesn’t feel natural to encourage your child to stay in an anxiety-provoking situation. And then I also like to do a lot of the skills we do with the client themselves, the child client, with the parent or other caregiver. For example, “What’s coming up for you in your body when you watch your child be anxious? What worry thoughts do you have? What might this mean about you as a parent, if you’re not letting your child come into your bed at night?” And so, I think those similar things that we talked about with kids can be helpful to also talk about with parents. Like Lesley was saying earlier, too: it makes a lot of sense that you do this because you feel better, and the child feels better. It makes sense that you’re encouraging this sort of avoidance unintentionally.

Norris: I totally agree, Margaret, and I think, broadly, just this nonjudgmental stance towards the idea of reassurance-seeking and accommodation is super important. And I think language is always important in therapy. But I think being really intentional with your language here can be helpful. I think Eli Leibowitz talks a lot about parents being drawn into the child’s difficulty or the child pulling for reassurance-seeking behaviors, and I think it puts the onus on the child’s anxiety disorder as what’s doing these things. I think a lot of parents come in with this unspoken—or often spoken—idea that they somehow caused their child’s distress and are operating from that framework. If I take that same approach, they’re never going to want to be working on the kinds of behavior change that I want them to do. So, I really want that nonjudgmental approach to permeate throughout all these discussions.

Crane: The other thing I often think about with parents in these discussions is, “What do you want for your child in the long term and what sorts of lessons do you want to be teaching your child?” Like Lesley was saying, I think even that language is important to think about when you’re using it to make it so it doesn’t feel like it’s blaming them. But thinking about, okay, in the long term most parents want their children to be independent. They want them to be able to emotionally handle many different situations. And it’s hard to do that. And so, a lot of what we’re going to be doing is practicing and sort of linking it towards their long-term goals. I think it can also help with parent buy-in for decreasing avoidance.

Norris: One of the skills that we use with kids is for us to model our own worries. I will say things like, “I just gave a presentation, and I felt worried in my body here, and I noticed these thoughts, and this is how I coped with it.” I find myself modeling this also with parents, which I don’t know if we do enough of, modeling how easy it is to accommodate anxiety, something we all do, again, because anxiety pulls for this. We see a kid who’s in distress, and we want to help. So, I’ll say, “As a therapist, I’m going to be looking out for my own accommodating behavior.” Maybe I’ll be pulled to want to have your child do a slightly easier exposure or something like that, and I’m going to be noticing that in myself and working against that. I think this opens a door to invite the parent in to consider their own accommodating behaviors, because it is something most adults do; we aren’t just singling out the parent here.

Snyder: These clinical examples are great because I think other therapists and clinicians are going to be struggling with that, too, with thoughts like, “How do I push these kids?” or even just the clinician thought “I want this kid to like me so we can do the work.” Clinicians are sensitive to the working alliance; we care so much about that, especially early in training or early career.

When talking about the idea of modeling, that worry is really protective. Where do you guys help the parents draw the line on what’s the anxiety and what’s natural worry? For instance, if I give a presentation, I’m going to have those butterflies, or if I’m doing an interview, I may have worries but that can be something motivating in the right context. So, how do you make that distinction between the helpful worry and the not-so-helpful worry?

Crane: That is where I lean on the diagnostic system a little bit, which is thinking about, “Is this impairing? How is this getting in the way?” Anxiety itself is not a bad thing if it’s not getting in the way and if it’s not really distressing where it is getting in the way of someone being in the moment of whatever it is they need to do. I also like to think about that with parents when we’re setting goals and expectations for treatment because our goal is not to get rid of anxiety. It’s to make it so that the child can cope with anxiety and can still do all the things they normally like to be doing with anxiety being present. I think it can be helpful, both to help parents know, “okay, when is this a problem,” and then it can also be helpful for parents to have expectations during therapy of, “what do we want the goal to be.”

Norris: I also love this question. It’s so important, I think, first, the introduction that some anxiety is normative. We expect that; it’s important as an intervention, just to let families know our goal here is not for your child to never to feel anxious ever again. We’ll have kids imagine what a world would be like if people didn’t feel worried, like, people being hit by trucks all the time because they just walk across the street, things like that. Here we often rely on this metaphor of a true alarm versus a false alarm. We’ll ask if they ever cook and their smoke detector goes off, and there’s no fire. That’s the type of worried that we’re going to want to work on, where you’re feeling like there’s a tiger in the room, but there isn’t a tiger in the room. I don’t want you to not feel worried if you’re presented with a tiger, and it’s a really scary thing. And I think that that’s also where some of the extra externalizing language can be really helpful.

Crane: My tiger in the room.

Norris: Yeah, exactly. It is really defining that external anxiety monster or whatever they choose to call it, as a false alarm worry. Our goal for these kids is really to educate them that it’s not that you’re never going to feel worried, but with treatment, you’re going to be able to choose whether or not you want to do whatever the monster tells you, or whether you want to do what you want to do.

Snyder: I love that, too, because it’s the idea of knowing when it is impacting functioning. That’s when we get into the realm of pathology. That may be a good lead into assessment when we think about functioning, so before we move on, any last thoughts related to engagement?

Crane: This can be a little bit harder via telehealth, but helpful to think about when the child doesn’t want to go to therapy. I say it’s harder via telehealth because we’ve been noticing in our clinic that the child doesn’t want to go to therapy, so they’re not really in a different setting. Being at home for therapy gives a different frame of mind, where the avoidance is different. It’s not a matter of coming to our clinic; it’s a matter of avoidance in a space where maybe they find that avoidance helps. It can be a big fight for parents to bring them to session, and so setting a goal, like let’s try for X number of sessions and reevaluate at that point.

Snyder: Thanks for sharing that because I think we have to adapt to the realities that our clients are going through, especially during our current pandemic.

Ok, so assessment. A clinical phrase I’ve heard is that anxiety is anxiety. But I’m interested to know the primary drivers of anxiety that you can see when you’re doing assessments. What do you see the most in your clinic? Are you seeing more social anxiety or separation? Or school refusal?

Norris: I think the most common diagnostic presentations that we see are more often a combination of what we call the “big three” disorders: Generalized Anxiety Disorder, Social Anxiety Disorder, and Separation Anxiety Disorder. I actually happened to run some descriptive recently on a subset of our clinic sample, and GAD was actually our most common primary presenting problem (I think the N in this sample is 92), followed by social anxiety, and then there was actually a pretty big drop-off where separation anxiety and specific phobia weren’t very common. At the bottom of our sample was panic disorder, agoraphobia, and illness anxiety disorder. We only saw like one case of illness anxiety disorder in the space of a four-year period.

Crane: The thing that’s interesting about anxiety is that they cluster together so often that sometimes in our intake reports, we do describe each anxiety disorder separately, but will say the common feature of this is anxiety. In some ways, the different disorders can be helpful to think about different situations that we might need to do exposures around. For instance, we should think about separation and how that’s interfering, or we should think about how social situations are interfering; how school worries and perfectionism might be interfering, and so on. The way that those different anxiety disorders are treated are the exact same way, with OCD and PTSD being a little bit separate. I think the diagnoses are helpful because then they help guide treatment.

Snyder: Right, what is interesting is that the most common co-occurring disorders are other anxiety disorders. I’m interested though, how are you assessing the child globally then with the anxiety itself?

Norris: We always administer a semi-structured diagnostic assessment, and we do it separately to both parent and child. Administering them separately is obviously very time and resource heavy, but we found that that’s worthwhile, because you get different information from parent and kid, which is really interesting. For example, a seven-year-old may have a harder time reporting on their own symptoms compared to the parent, and then a teen might know their social world a lot better than their parent. So, doing them separately has been really helpful for us. For other measures, we don’t have as much of a common battery, but we do tend to always try to include a self- report measure of anxiety. We usually use the SCARED.

Crane: We’re a research clinic as well, so we have a research battery. But if I were seeing clients outside of our clinic, I really like the SCARED, in part because it’s free, and the subscales can map onto DSM disorders. The Spence also does that, and I think it’s also actually free. I like both of those again because it can give a very brief sense of what might be going on, and this is where I see assessment really guiding treatments. I might do a questionnaire to understand diagnostic subsets but also to get a sense of what exposures will look like.

Snyder: You are already introducing the clinical language to the kid, so when you are doing an exposure, you can look back at the SCARED, let’s say, and tell the youth, “Remember when I asked you about X, Y, or Z scenario? Well, we are going to talk a little more about that today.” It gives predictability in a way, and it also gives the message to the youth that we are doing these assessments for a reason, not just to check boxes.

Ok, so second part of the previous stack of questions: what comorbidity are you seeing, and how does the presence of another disorder affect your treatment planning?

Crane: I’ll start off by saying yes, comorbidity is the norm and expectation. We see comorbidities across the spectrum with OCD, depression, ODD or ODD-like behaviors, and ADHD. If there’s some behavioral concerns, that’s where we might use more behavior management strategies in session, so more rewards, or I’m chunking the session into smaller pieces with more time for games, perhaps. Maybe the kids don’t have to be sitting down when we’re doing the session, and they can be moving around. For comorbid depression, the nice thing is that while yes, the Coping Cat really is talking about anxiety, the skills in the Coping Cat protocol or any CBT program that has content related to “encouraging opposite action,” can be tailored behavior activation, really. You still use an exposure framework but make that more of a ladder of different situations to build up.

Norris: Another co-occurring disorder I want to add would be Autism Spectrum Disorders. We see a lot of co-occurring anxiety within that population, and Dr. Kendall and collaborators have recently done an RCT that shows CBT is actually efficacious for kids with ASD. I’ve been working more regularly with clients who also have ASD, and what is interesting is that even in the context of a social exposure or a social worry exposure, you can build in social skills as part of that. Also, when you’re talking about identifying how you’re feeling anxious, locating where you experience it in your body. With this group, you can again broaden that to just say, how do you feel in your body when you are sad, mad, or happy. Just extending it to have it be a little bit more broadly focused on different kinds of emotions.

Snyder: It’s great to see all the connections you have made naturally in your responses between engagement, assessment, and intervention. There’s one big piece I still need to bring in: school. School is a kid’s job; developmentally, school is what they do. How much do you engage the school in the assessment process, and how much do you involve schools in the treatment process with your youngsters?

Crane: That’s something that I feel really fortunate about with the structure of our clinic, that we involve schools a lot, and I think we’re able to do that in part because we’re a training clinic, so perhaps we have a little bit more time. It’s also something that our clinic really values, to involve everyone we possibly can in some way. I’ve also spoken to people like soccer coaches and swimming coaches. Some of you might talk to a music teacher or someone very involved with music. As many people we can involve as possible is helpful to get perspectives of how this might look in different settings, and then also to getting everyone on the same page. We found that some schools can do similar behaviors as parents do, like unintentionally encouraging avoidance or accommodation. Some school accommodations for anxiety are helpful, where they slowly help a child face their fears, while others are not helpful. With these not helpful ones, they’re removing an expectation so that the child isn’t feeling anxious. So, a lot of the times when we’re working with school as well, we often will say, “Can we not have this sort of accommodation right now because we are working towards the youth working through their anxiety.”

Norris: I agree. Oh, we love to get teachers involved, especially in the intervention phase, where we are introducing teachers to the model that we operate from, which is really helpful. But this question made me think that we actually don’t involve the school in the assessment process as much compared to intervention, and I think we probably should do that more.

Snyder: It makes sense; schools and teachers are well-meaning because they want their students to learn, so they might provide these accommodations that unintentionally reinforce the avoidance or reassurance, essentially an accommodating of the unwanted anxiety behavior. And when you intervene, you’re still assessing; it’s all feedback.

Norris: A critical piece is the idea of informed consent, just because I’ve had really mixed responses from kids about how they feel about me talking to their teacher or doing any challenges in school. I think some kids are totally fine with it, and other kids feel embarrassed that they’re attending therapy. Informed consent goes beyond just signing a form and saying it’s okay, so really talk through consent with a kid, and let them know what’s going to happen.

Crane: Last point for assessment, tracking progress throughout treatment. I really like the coping questionnaire or the youth top problems questionnaire, and these are ideographic, so they are customized to the client. You can really see how we are progressing with these goals throughout treatment. Those assessments are also both free, and they’re also both really short, where I think there are only three items (I would only choose one or the other). There’s also no technology problem with scoring it; its quick, easy, and available.

Norris: This is making me remember when I first started as a clinician, I thought that I would be using diagnostic information a lot in creating this really personalized coping experience for the family, but now I never want to be leaning exclusively on that diagnostic information, especially because there’s so much overlap. I want to think, what does the family structure look like? What is the family’s cultural background? What’s their socioeconomic background? That’s the piece of information that we don’t get in a lot of our measures, so take a step back and really see the family, not just the diagnostics.

Snyder: Excellent, the value of a really good formulation to contextualize all these data points that we get to tell the clinical story.

Crane: Yeah, I think that’s particularly important because families have different cultural or behavioral practices around things like sleep behaviors. If a child has separation anxiety, we might think about co sleeping and the parents as being a problem. But for many families, it’s not a problem. Consider what makes sense for the family and what their values are- what’s normal based on their culture, I think is really important with sleep in particular.

Snyder: Great way to cap off assessment, because everything requires context. Let’s shift now specifically to intervention. You both are part of Dr. Kendall’s lab, which is known for Coping Cat. It may be easier to use that as a jump off point. So tell me, what’s it about, what’s its evidence base, how do you implement it?

Crane: So, I guess a few things with evidence. Evidence shows that Coping Cat is one of the most effective therapy treatments for kids (it’s not effective for everyone) I think it’s around 60 to 80%, depending on the trial. The most effective approach is the combination of the program with medication. That doesn’t mean that I think all kids should go on meds. In fact, I think trying therapy first makes a lot of sense because there’ll be fewer side effects. But it can be important to consider depending on the client.

Norris: The first year it was implemented was in 1994, and there have been a ton of trials since then showing effectiveness. I think it’s important to tell families about the options for treating anxiety, with medication being an option, or a combination of medication and therapy. The other message to send to them is that realistically, gains can be maintained, but sometimes kids may need some boosters. The big thing for Coping Cat is seeing how to adapt it to make sure that we are providing culturally sensitive and responsive care. I think there have been studies done in the Hong Kong and Argentina, but we need to really broaden how to adapt to be responsive across race and ethnicity.

Crane: In terms of the Coping Cat program itself, one big term to think about with any manualized treatment is “flexibility within fidelity,” which is basically to say that it’s important to stay consistent with the core principles of treatments but the exact details and how they’re implemented can be very flexible. That can both help people adapt the treatment to the individual client and be more culturally sensitive. Also, it can just help with adapting it to different situations, like sometimes some kids don’t have as many sessions as other kids. You may need to think about what information should be longer or shorter.

The typical Coping Cat program is 16 weeks, but there’s also a brief version that’s eight weeks. There’s also a version that is computer assisted therapy, called Camp Cope, and that’s online where basically the computer does the psychoeducation part, which includes things like coping thoughts. Then, the therapist or whoever’s administering the program helps with the exposures live. To give a brief structure of the Coping Cat without going into all the sessions, the first half is helping kids identify different thoughts, feelings, and behaviors. It uses something called a fear plan. F is feeling frightened. So that is working with the youth to see, where do I feel anxious in my body? The same with relaxation: how can I feel a little bit calmer? The “E” is expecting bad things to happen, and that’s what we think about with anxious thoughts. We also think about cognitive restructuring or also accepting thoughts. Sometimes these thoughts are accurate, but they’re just not very helpful in this instance. Or it’s a thought we have to accept, and we need to see how we can keep going.

The “A” is actions and attitudes that can help. Cognitive restructuring lends itself to attitudes of “what can I tell myself so that I can approach this situation that might be scary for me?” And sometimes that’s just a simple thing that is really hard, but I’m going to give it a try. And then the second part of that A is actions that can help. That’s where we think about problem solving. Sometimes people feel anxious because they’re overwhelmed, or they don’t know how to approach a situation. I found problem solving is a really helpful skill for anxious kids. And lastly, the “R” is results and rewards. In this step, we help kids remember that we’re not looking for perfection. We’re just looking for effort, really. We’re not looking for social interaction to go perfectly. We’re just looking for “Okay, did I actually ask my friend to hang out today?” Because that was the goal. They get rewarded by other people and other external rewards, like praise or getting to pick what’s for dinner. That’s actually one of my favorite rewards across clients. It can also be tangible things sometimes with teenagers, especially. They might use points to build up to getting new shoes or something like that. We also talked about self-rewards like giving yourself a pat on the back.

Norris: I summarize it to families this way: the first phase is learning skills, and the second phase is practicing those skills. I use a silly example with kids: I can learn all I want to know about the organ, but I can’t play it until I actually put my fingers on it and practice. The exposure part is really just putting those skills into practice. Throughout the first half of treatment, we will create these fear hierarchies with the kid, which are really just personalized worry ladders for them. I call them fear islands with the kids, and it just really breaks down their fear into small manageable steps. For instance, if a kid is afraid of spiders, a fear ladder might be looking at a picture or cartoon spider, then looking at a picture of a real spider or watching a video of a spider, then being in the same room as a fake spider, all the way up to maybe holding a spider.

For our first exposure, we usually start around like a three or four level on a scale of zero to eight. We will do the exposure with them in session and get ratings of how their worries are throughout the exposure. Then we always give them a reward at the end because they were brave; we always want to reward brave behavior. It’s the process, not the outcome for them. And then we’ll plan for at least three challenges a week (We call them challenges with the kids, not exposures, because exposures is a weird word to use with kids). We’ll plan for three challenges that they’ll do, and then we’ll also plan for the next challenge that we will do when we see each other next session. It’s a really flexible process.

Snyder: That’s helpful for folks because it’s unveiling what’s behind the curtain, which can reduce the worry or hesitancy to do manualized treatment, or to reduce clinician worry about exposure, because some may think “I’m emotionally harming my client.” So, there can be some anticipatory worry on the part of a clinician new to exposure work.

Crane: Final things with the protocol. In the last session, we always create an advertisement or a video. Basically we have the child tell another child “here’s what I learned.” It’s essentially a relapse prevention plan, but it’s a little bit more fun. Some kids would rather make a poem or a rap or just write it down. Any of those are fine. The goal is just to help the kid reflect on what they’ve learned from treatment. They may even just go through the fear plan and then talk about which of the different challenges or exposures were really helpful for them. We also talked about things like “how do I know when I need to come back to therapy?” I’ll just mention that while Coping Cat is 16 weeks, there are definitely some clients who may need more like 20 sessions. We might add in some more exposures than the classic 16 sessions. Sometimes clients are done within 12.

The other key component in Coping Cat is the homework piece. We call this the “stick task” or “show that I can,” which is basically practicing throughout the week. I always say, “You only see me for one hour week, and we want to make sure you’re thinking about this between sessions.” The other key piece is involving parents, which clinicians can avoid. At the end of the session, I say “Here’s the skill we learned, and here’s how you can help your child practice. Throughout the week, talk about where you are noticing worry in your body, or even if you’re watching a TV show together. You may ask in a line at the store, how do you see worry in that other person in line? Help the parent apply the skills. There are two parent sessions in Coping Cat where we really talk in more depth about what parents can do. We see the over-accommodating parent to help the child avoid anxiety, and another type of parent we see is the very strict or harsh parent. These parents may need a little bit more buy-in to do things like rewarding their children for great behavior, or more attention to the parent’s response to the child’s anxiety which perhaps is making their child a little bit more anxious. Any parent needs the rationale of treatment. Think about the goals and get a consistent, adaptive parenting response. Lastly, we also see the inconsistent parent, meaning the parent might accommodate the child, and other times they might not. For these parents, we try different parenting skills like tracking and self-monitoring.

Norris: In addition to parents, the clinician experience of doing exposure is so important. Many studies show that doing exposure doesn’t rupture the alliance, and, if anything, it can strengthen it. My stance of exposure is that you can’t have a bad exposure. There’s a lot of worries about an exposure going wrong, where therapists have this image of a kid just completely breaking down and thinking “I broke in this kid. I don’t want that to happen.” We obviously don’t want that; we want the kids to have a mastery learning experience with their exposure. But let’s say you start an exposure, and it ends up being a lot harder for the kid than you thought it was going to be. That’s okay. That experience is more data for you so you can really understand what this kid’s actual worries. That experience can help create this more personalized exposure hierarchy.

When you’re going into exposures, plan for those moments ahead of time with the kid. You may see that your client is feeling super great today and what was planned was no big deal. You might challenge them or let them pick out what they want to do off the hierarchy. Make it collaborative in that space, and let them know when doing these challenges, that it could be hard, but that you’re doing it together.

Setting up some ground rules with the child can give them a sense of efficacy, like “We’re doing this together, and exposure is never something I will do to you; it is something I do with you. And I’m never going to ask you to do something that I would be willing to do myself.” Ultimately, exposure can be fun for kids if you make it that way.

Crane: Exposures can be a confidence boosting experience for kids because they’re doing something they didn’t think they could before. That can also mean planning for what they’re going to do at home with their parent for homework. You’re not there with them, so make it something simple, realistic, and targeted to what you’re trying to achieve. So maybe instead of a specific situation, you may say, what would make you embarrassed and what would be hard to stick in the situation? If when you practice at home and you’re not embarrassed, how can we make it a little more embarrassing? That both teaches the child how to be a therapist, which is important for the long term because you’re not going to be there their whole lives, and it also helps the at-home practice be a little bit more effective. Make sure that whatever they practice is really getting at their core fear.

Norris: I spend a lot of time with kids, making sure they understand the model and why we’re doing what we’re doing. I want them ultimately to be able to come up with their own exposures and not think we’re doing this random thing for no reason. I want them to really buy into that model. Something else to consider is unconditional positive regard, where as a therapist, I believe that this kid can do it and that they are brave children. I’m just helping them to learn they are brave. Kids really buy-in with that positive feedback and positive regard. The goal, again, is not that they’re not going to feel worried, rather that they understand what to do when they feel worried. The hope is that they know that bravery is what we’re looking for.

Crane: Parent involvement goes a long way with that, too. For some parents, it can be really helpful for them to be in session during exposure to observe it, because sometimes parents might think, “Oh, that’s too hard for my child.” So, for them to see both that you the clinician are confident that the child can do it. and for them to watch their child do the exposure and may see “Oh, my child couldn’t cross the street because they were so nervous about getting hit by a car. This wasn’t actually all that hard when the therapist had this structure and really believed in them and could reward them.” I think it helps give the parents that confidence to then practice it at home.

Norris: Accommodating and reassurance seeking can inadvertently send a message to the kid that the parent doesn’t believe they can do that thing. Exposure is us sending the message to both parent and child that, “We know you can do this thing and we’re going to get you on board with our beliefs that you can do it.”

Snyder: It goes back to modeling then, for both the child and the parent. You both have mentioned about being brave, and it’s flexing that brave muscle to building resilience. Resilience is not a character trait; it’s something that we can work on, and it’s something we can learn. That’s a great takeaway for readers, to use that language about being brave.

It’s been so great to hear all the things that you’re talking about, from active ingredients like cognitive restructuring, praise, and reinforcements, to talking about what it is like for new clinicians to actually do exposures. What parting words do you have for our readers?

Crane: Especially as you’re learning a new program, it’s really helpful to have either supervision or peer supervision or consultation. A great paper by Emily Becker Haimes looks at what’s different about these specialty university clinics structure wise, that enables them to do exposures and to do these therapies more effectively. The one thing is that clinicians in these clinics have peers. I really love our clinic’s peer supervision because it helps with generating ideas for exposures, and it’s so much easier to do that with other people. There are various lists online and on various websites, but I think if you really want to customize it to a child, it’s really helpful just to have someone to bounce ideas off of. For trainees or newer clinicians, if that structure doesn’t exist try to see who else in the clinic is doing exposure work and do peer consultation outside of their regular supervision.

Norris: I think we psychologists love a “yes/and” statement. I never want to lose sight of how difficult what I’m asking these kids to do is. Sometimes new clinicians can both be worried about exposures, but also overzealous in their application of exposure, so I always want to really be inspired by and be honored to watch them do this thing that’s difficult for them. And at the same time, I don’t want it to be a serious thing that is inaccessible to the youth. I want to create a playful experimental environment in the session, bringing some laughter into the room while we’re doing this really hard thing and holding space for both those things at once. So, yes this is hard, and I know you can have a good time trying. That’s the goal of therapy, getting to that middle; the middle ground is right where we want to be.

Snyder: The middle way is the way to go, where we don’t want to be overly worried or unresponsive to stimulus. We may say to clients, “We don’t want to completely take away your anxiety, and we don’t want you to be anxious all the time, so what’s that middle ground look like for you?” And that conversation puts them in the driver’s seat, where they are able to thrive and not be driven by their anxiety. To end with a very therapist-like statement: how can our anxiety serve us better?

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