Biology Counts—But Not Much
Child professionals, I’m sorry to say, are often unconsciously complicit in maintaining and reinforcing a child’s anxiety. Like parents, many therapists are so anxious to calm kids that they neglect to help kids handle their anxiety. Anxious kids don’t want to do anything that makes them uncomfortable. Knowing they ultimately have to do those things—get on the bus, go to school, see the dentist, sleep alone in their own beds—is what brings them to the therapist. The hitch is that while parents and kids want the child to do the necessary things he or she fears, they want the child to feel relaxed while doing it.
Many therapists seem to agree with the parents that helping the child feel better, calmer, and safer at all times is somehow the main point of therapy. Other therapists teach relaxation techniques or deep breathing and stop there, so that the child never learns to tolerate anxiety. Defining success as being able to go into difficult situations and feel relaxed virtually sets the child up for a lifetime of anxiety. If continual relaxation were the standard for successful living, how many of us could stand going through a job interview? A first date? A colonoscopy? Moving away from home? Being able to calm your body and slow down is a great skill, but it’s a skill, not a cognitive shift that enables the child—or anybody—to live with and handle feelings of discomfort, vulnerability, and uncertainty. The first time it doesn’t work (and it won’t work if that’s all there is, I guarantee), the child returns and says, “I still can’t feel comfortable at school, so I can’t control my anxiety. Those skills don’t work. Your treatment doesn’t work.”
Do Something Fast
By the time I see them, worried parents and their anxious kids have frequently been through several stints of unsuccessful therapy, and have been told by professionals that their child may have a serious, possibly permanent mental illness. Or parents have been told that the doctors don’t know what’s wrong with their child because medical evaluations for physical symptoms like stomach pain, headaches, and sleep issues have come back normal. Parents swing between hoping I can help and being skeptical that I’ll have anything new to offer.
Momentum is critical—I have to move fast to win them over, give them some hope, and get them to come back. My goal is that by the end of the first 90-minute session, they’ll not only feel more optimistic, but will get a taste of victory over the anxiety bugaboo—and have fun doing it. My expectation is to see significant and noticeable improvement between the first and second session. This means I won’t spend much time getting history in that first session, because once the child is in the room with me, my job is to engage that family in an energetic experience that shows them immediately how to change their patterns and create a new relationship with this thing called anxiety. (I’ll tell parents to e-mail me what they think I should know, or even meet with them separately first if they have a lot to share.)
Such is the case with Perry and his mother, Beth, who first come to see me a week after Perry has turned 9. Because of Perry’s rather dramatic symptoms, they’ve been to many healthcare providers. At this initial appointment, they’re both a bit shy and polite as a worried Beth gives me the history. Since preschool, Perry’s been vomiting. “I don’t like looking at disgusting foods like mashed potatoes and tuna. I feel like I need to throw up,” he tells me. He had a full gastrointestinal workup—completely normal—and was referred to occupational therapy for 10 weeks. Though he has been cooperative at his occupational therapy appointments, the vomiting remains constant.
At home, he has to leave the dinner table often, usually after about three bites of food. When the family tries to go out to dinner, he leaves the restaurant to throw up, either in the parking lot or the car. At school, he eats lunch alone, on a bench in the hallway near the bathroom. His grandmother is the school secretary, so he goes to see her when he knows it’s going to be a tuna or mashed-potato day. When Beth took Perry to see his pediatrician, the doctor told her, “He’s a complete mystery to me; I’ve never seen anything like it.” The GI doc put him on a prescription medication to increase his appetite in the hopes that he’d gain some weight, but the doctor had no other advice about the vomiting.
We talk for a few more minutes. I want to learn as quickly as I can how Perry and his mom view the problem. As Beth talks, I’m listening for certain things. Do they see it as a family legacy? “My mother and grandmother and Aunt Trudy all have anxiety, so it’s in our genes.” Do they notice that the anxiety “comes and goes,” or do they describe the child as “always anxious”? Do they use lots of global words that reveal how huge and pervasive they see the problem? “It’s ruling our lives; it’s never-ending.” Do the parents repeatedly say things in front of the child that reinforce his identity as an anxious child? “He’s been this way forever. Even when he was a baby, I knew he was going to be a worrier. It’s who he is.” The words and phrases help me identify the patterns that I’ll need to address, and they’re rather predictable: anxiety is usually experienced as a big, permanent, genetic, overwhelming constant in people’s lives.
Beth briefly tells me about her own struggles with anxiety. As a child, she was a perfectionist in school, had some counting rituals, but nothing that intrusive, and when things didn’t follow the plans she made, she’d “freak out.” She began having panic attacks in her early twenties, but she’s been managing them well for the past few years. This is good: she knows that this problem can improve. When the occupational therapist, who knows me well, suggested to Beth that this might be an anxiety issue, Beth scheduled this appointment: also good. She listens to suggestions, and follows up. She’s looking for solutions, and, though confused, she’s far from hopeless.
Externalize: “I’m Not My Anxiety—My Anxiety Isn’t Me”
I ask Perry what he thinks. What makes him throw up? “Sometimes my brain tells me to throw up. I have a good imagination. I won the Best Imagination Award at school.” Pay dirt. Perry has already started to externalize and compartmentalize the problem. He sees his brain, his imagination, and himself as separate. He “hears” his brain, or what I call the worry part, “telling” him to throw up, and he values his good imagination.
I ask if anything else makes him feel worried, even if he doesn’t actually throw up. Mom reports that he’s not great with changes, like starting a new school year. He gets “a bit freaked out” when he arrives at birthday parties that are chaotic, and he knows better than to watch scary movies. With that imagination of his, scary movies stick around in his head for way too long. This is important information, because all the other professionals have been focused on food, on content. Teaching Perry how to tolerate tuna would be nice, but teaching Perry how to deal with unexpected unpleasantries and his souped-up imagination is far more useful. This isn’t really about food, and that’s what I must help this family understand right away. So, after these first 10 minutes or so (remember, the clock is ticking!), I get to work. Perry needs to learn how anxiety operates. I want him to understand how it works in his brain and body and, like a magician explaining just how he gets his special effects, I want him to see that anxiety isn’t that mysterious, once you know its secrets.