A watering can waters only the top of a family tree where the parents are
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Health

Giving Parents Therapy Can Help Their Anxious Children

A new treatment program reveals how our mental health is shaped by our family and the ways we interact with them.
April 16, 2020, 12:12pm

Last year after my grandmother died, I stood in her apartment in Houston, surrounded by her things. A piano. Stacks of classic movies. A figurine of a white peacock. As I took in the room, my feelings of sadness were eclipsed by another thought: Why are there so many flashlights?

There was one on the coffee table, one near the TV, and several in the kitchen. One—waterproof—hung in the shower. My aunt gathered them all together and we stared down at them. “She didn’t like to be anywhere without a light in sight,” she explained.

There, in the form of flashlights, was a symbol of my grandmother’s anxiety. What if the power went out? What if it happens while I'm in the shower? What if I need light, and I can’t reach the switch? Her solution was to buy more flashlights.

I was no longer puzzled. I don't obsess about flashlights, but other worries that pestered my grandmother were similar to those that crop up in my own internal monologue, like food contamination, sickness, and germs. Like my grandmother often did, I've wanted to cover surfaces before touching them, and repeatedly wash my hands. I've focused on peculiarities around how things need to be done, and in what order, and stressed about what others thought of me.

Anxiety is heritable, meaning that if you have family members with anxiety, you're more likely to have anxiety yourself. Wherever you look in my family, there are traces of anxiety. It lurks in every corner, like my grandmother’s flashlights. It's in our behaviors, our purchases, our fears, our Google search history, and the ways we connect with each other.

When I was growing up, my father designated a hand towel for each person in our house, to prevent the spread of germs. He had a food-labelling system to ensure our food hadn’t spoiled. My great aunt (my grandmother's sister) told me once that she wasn't any fun at picnics because she overly fixated on having enough ice to keep the potato salad from going bad. My sister is ten years younger than me, and grew up when I was mostly out of the house. Yet we share nearly identical phobias: vomiting, swallowing pills, concerns around sickness, social anxiety, and perfectionism.

Mental illness is caused by a complex interplay of genes and environment, both of which are influenced by your caregivers. At some point, I stopped seeing the use of trying to tease these factors apart. Since both my genes and my environment are anxious, both roads lead to the same, inevitable destination. I am anxious because my family is anxious, as a unit.

But a program developed in the last few years at Yale University by psychologist Eli Lebowitz seeks to make good on this fact—that anxiety doesn't reside only in the individual—rather than use it as an excuse to submit to one's fate. It's called Supportive Parenting for Anxious Childhood Emotions, or SPACE. In 12 weeks, it helps children with anxiety disorders get better, not by treating them, but by treating their parents.

Until last year, there were almost no studies that tried treating parents alone for their children's anxiety, and none that compared that approach to cognitive behavioral therapy (CBT)—the gold-standard anxiety treatment. In recent randomized trials and his ongoing research, Lebowitz is finding that SPACE works just as well as CBT, without a child going to a single therapy session.

Families may be making each other anxious out of an overwhelming desire to protect each other.

While we can't change our genes, this result shows that the interactions between anxious people, like parents and children, are important, and can be modified in ways that are beneficial. SPACE works by focusing on one specific interaction between family members: the changes in behavior parents make when trying to help and protect their children from their fears, which is called “accommodation.”

When I first heard about SPACE, it was a "gotcha" moment for me—finally, the proof I wanted that parents project anxiety onto their children as a result of their own unresolved issues. But as I learned more about it, I discovered that the SPACE program actually complicates this common desire to blame parents.

Accommodations from parents are the things they do in response to their kids’ anxiety, meaning that some level of inherent anxiety came first. SPACE reveals how anxiety isn’t merely passed down, but is thrown back and forth between parents and children, like a game of catch in the front yard. Further, it’s not just that parents are subjecting their kids to their own fears and neuroses. Families may be making each other anxious not by all drinking out of the same poisoned genetic and environmental wells but out of an overwhelming desire to protect each other.


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There's long been an interest in involving parents in an anxious child's treatment. The problem was, it didn't seem to help. "By and large, those experiments failed to find significant enhancement,” Lebowitz said. “Not to say children didn’t benefit, or parents didn’t benefit, in other ways. But the key question was, Would the child’s anxiety be more improved if you worked closely with the parents? and by and large, the answer was: not really.”

Lebowitz is a thin, brown-haired man with glasses with the calming nature of someone who frequently has to explain things to freaked out parents. We're sitting in a sparse room at Yale University's Child Study Center, where parents who start to notice their children acting differently—crying and being scared, refusing to go to school, afraid of being alone—come to seek help.

Lebowitz said that it might have been what therapists were doing with the parents that led to no improvements. Often, they were training parents to become pseudo-therapists themselves, teaching them CBT concepts to try at home.

His PhD dissertation was on families with a child with an anxiety disorder, where he found that anxiety-like behaviors could spread. One way was through accommodations, in which parents of children with anxiety and OCD were much more likely to get involved in OCD rituals, to try to help their kids avoid anxiety, or to allow them to change their daily routines, all in an effort to make the child's life easier.

But these accommodations reinforced beliefs about the world that were wrong. One young patient of Lebowitz's was plagued with thoughts that he would stab his pet dog. When he told his parents about it, they separated him from the dog, so he didn’t have to worry about what might happen when he was left alone with it. They took the knives out of the kitchen.

“It seems like they're trying to make him less anxious by saying, 'Look, here, we're putting protections in place,'” Lebowitz said. “But from the child's perspective, if my parents are putting away the knives and keeping the dog away from me and making sure not to leave me alone with the dog—it seems like they also think that I'm dangerous.”

There’s a difference between these accommodations and accommodations made for kids with physical or learning disabilities, which are entirely different. Most of the impairments in anxiety and OCD stem from a person’s unwillingness to experience anxiety, not an actual physical inability of some kind, Lebowitz pointed out.

“That’s true with all anxiety problems,” he said. “I’m impaired because I don’t want to feel anxious, and if my solutions are all built around not feeling anxious, then my impairment is likely to escalate rather than the opposite.”

Any family or friend of someone with anxiety will recognize this pattern: My aunt accommodates my grandmother by buying her another flashlight. I reassure my sister that the salad dressing we've eaten hasn't gone bad. My father takes me to the doctor to be certain I don't have that obscure disease I'm worried about. We all feel better for a moment, but we don't learn a more useful lesson, which is that we're capable of facing the imagined danger we're avoiding. After learning about accommodation, I sometimes pictured my family stuck, as if in a Chinese finger trap, because we're all pulling so hard, exerting so much effort to accommodate our anxiety, that our surroundings have closed in around us tight.

“Parents are often expending tremendous amounts of time and energy to accommodate their children's symptoms,” Lebowitz said. “But the child's anxiety is actually getting more severe rather than less severe.” And so, Lebowitz decided to hone in on accommodations, to see if lessening them in a parent could help a child.

Children ask a lot of questions about why something is this way and not another. But questions from Ian, a seven-year-old who lives in a suburb near New Haven, had turned from gentle curiosity towards something darker. They were riddled with anxiety. He repeated the same ones, worded slightly differently. What's a disease? What's cancer? Am I going to get sick? How do I know I won't get cancer? Sometimes the questions were about other impending crises, like the weather—tornadoes, storms—or black holes.

We're exerting so much effort to accommodate our anxiety that our surroundings have closed in around us tight.

Once, Ian's mom, Aimee, heard Ian crying and she asked him what was wrong. He was fixated on future events, when he couldn't be sure what would happen. In one case, he was worried about how he didn’t yet know how to swim, but was going to go to his grandma’s house for the summer—a visit that was several months away.

“These things weren’t even happening,” Aimee said. “But he was obsessing over it.”

Mornings before school started to be difficult. Ian was nervous to go; at school small things would set him off, leaving him in tears. He started needing someone to sit with him while he fell asleep. Aimee and her husband heard about SPACE, and signed up to be part of Lebowitz's trial.

SPACE schedules 12 sessions with a parent. Lebowitz has parents list, in detail, all the ways they have started to accommodate their child’s anxiety, by mapping out their whole day, from waking to sleeping, and all the things that are done differently because of their anxiety. He said that parents often don’t realize how many accommodations they’re making.

Aimee said that they had been answering all of the questions Ian was asking them, and staying by his side during bedtime to avoid him getting upset. “We just got so used to doing them that we didn’t even really think about it anymore,” Aimee told me. Lebowitz has parents pick one or two big accommodations to focus on, and they come up with a detailed plan for how to stop the accommodation.

He said he's not training parents to abandon their children emotionally. Instead of accommodation, parents provide a supportive response—conveying to their kid acceptance and validation of their experience, while also expressing confidence in their ability to cope. It sounds complex, but it's deceivingly simple. When a child expresses anxiety, you say that their situation sounds really hard, but you know they can handle it.

This is first done through a letter that parents write to their kids. In Aimee’s letter to Ian, she explained that she wasn't going to answer his anxious questions anymore, and that she was doing this to help him. They set up a time right before bed for five minutes of questions, with a strict deadline. If a question was asked at any other time, she would say “I know you're worried about this, but it's okay, you can handle it.”

At first, Ian fought back. He would say, “You want me to be stupid?” But Aimee said they stuck to the script, and the anxiety dissipated much more quickly than she thought it would. One night, Ian was crying about the five-minute question limit. After 10 minutes, he stopped. Shortly after, Ian told Aimee that he didn’t need to be accompanied to bed anymore. Now, he goes upstairs by himself and reads for a bit, and turns off his own light and goes to sleep.

“That was a turning point,” Aimee said. That was only six weeks into the SPACE program—halfway through.“I really didn't expect that much that soon," Aimee said. Last summer, despite still not having official swim lessons, he jumped right into the pool at his grandmother's house.

Lebowitz has found that most of the children he's treated indirectly improved a lot, even those with serious anxiety problems and OCD. “Sometimes the very best thing for a very anxious parent is to make one small behavioral change, and actually observe their child surviving, coping,” Lebowitz said.

Aimee said that she has anxiety too, and when Ian's anxiety would spike, hers would go along with it. It can create an endless loop: She would try to anticipate the next thing he would be anxious about. Ian's anxiety caused her anxiety, and because she already had anxiety, she felt more eager to accommodate his anxiety.

Intriguingly, these connections seem to reflect in biology too. In Lebowitz's research, he's also looked at children’s brains in an fMRI scanner while showing them different facial expressions, from neutral to threatening. Reliably, there will be activity in a certain region called the amygdala, and anxious children have a stronger response. If you do the same thing, but have a parent there, holding their hand, there’s lower amygdala reactivity and stronger connections between the amygdala and parts of the brain that are responsible for lessening the fear response. That reduction in brain activity can correlate with how much accommodation a parent does, and how much a child relies on their parent to make their anxiety go down.

In some ways this is normal: When children are afraid, stressed, feel threatened, they turn to their caregivers to protect them and make them feel calm again, Lebowitz said. It is in our nature to respond to fear through social behaviors, signaling to our caregivers and letting them know: I’m in danger, I’m scared, I’m upset. Our parents are wired to step in and provide protection.

“It’s how it’s supposed to work,” Lebowitz said. But anxiety in children can blur the boundaries that keep parents and children separate. “In the same way that an anxiety disorder can hijack healthy, adaptive anxiety systems at the individual level, like make your heart go too fast or make you sweat too much, it can also hijack that social aspect by causing children to chronically seek parental protection, seek parental reassurance, seek regulation, and causing parents to chronically provide it."

This is something that we all learn from a young age: Doing something hard makes it easier. Get back on the horse. But treatments work because people have been able to formalize certain truths about human behavior and health into therapy.

A handful of anxiety experts agreed this is where the SPACE steps out ahead of other parent treatment programs. Eric Storch, a psychiatrist and anxiety and OCD expert at the Baylor College of Medicine, said it's step-by-step and specific in a way nothing has been before. It helps side step children and have adults manage the situation. Therapy can be hard for kids, and not always effective. “One of the most common questions I get from parents is How do I help my kid? And the wrong answer is to sit in the waiting room,” Storch said.

Despite that, it’s very rare for a child to go to a therapist and have the therapist suggest putting the parent through some sort of training first, said Phillip Kendall, a psychologist at Temple University.

Our mental health doesn't exist in a vacuum, but is shaped by others, and the ways we interact with them.

Lebowitz said that the principles of SPACE work even for older children who still live at home—he's seen parents with children in their later adult years who are unable to gain their independence because of anxiety.

Yet, when I recently pushed my sister, who lives at home, to go to therapy, they asked about family history, but no one suggested that perhaps we try putting one of my parents through some sort of treatment first. Lebowitz is hosting SPACE training all over the country, but when I tried to find someone familiar with it in my sister's city, there was no one.

“I think that the traditional model of child therapy still is you know, drop your child off to visit, pick them up, take them home, maybe have a quick check-in about what happened in the session,” said Tara Peris, a clinical psychologist at UCLA.

Whether or not SPACE becomes mainstream, there are important lessons to take from it, Lebowitz said: Our mental health doesn't exist in a vacuum, but is shaped by others, and the ways we interact with them.

Your father or mother didn’t just gift you your fears, neatly packaged up and fully formed, the way they passed on hair color or scoliosis. Rather, via accommodations, their own anxiety might have interacted with your anxiety in real time. This transforms anxiety disorders in a family into a sort of neverending relay race, in which parents and children are running in circles and passing a baton back and forth forever, until someone can break the cycle.

My sister and I did get an official diagnosis for our anxiety—obsessive compulsive disorder—but others in my family have not sought treatment. When my sister is talking about things she's anxious about, I now actively try to not rush in and help. I don't try to diffuse the situation, to reassure her. Instead I talk about how she can handle it, and how proud I am of her for doing so. I've noticed that she has started to do the same with me. Whereas we often would talk and relate to each other about the parts of life that scared us, we now text each other about the ways we're conquering those fears.

This is the opposite of what I thought would happen. When I first began therapy, and started to get better, I felt like I was leaving my family behind. I was losing the one way we knew how to connect with each other, by being allies and helping each other in a world filled with anxiety landmines. But by recognizing the power we have over each other, and by acknowledging that the nature of that influence can change, I became hopeful that leaving my own anxiety landmines behind might help my family do the same.

How we treat each other could ultimately seal our fates. My own behaviors reverberate around me. But they don't have to take the form of accommodations. Instead they can teach my loved ones that they are strong, and don't need another flashlight in the dark.

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This article originally appeared on VICE US.