Avoidance Feeds Anxiety: When to Make Teens Do Hard Things | Dr. Meredith Elkins

The Ask Lisa Podcast does not constitute medical advice and is not a substitute for professional mental health advice, diagnosis or treatment. If you have concerns about your child’s well-being, consult a physician or mental health professional.

The following transcript has been automatically generated by an AI system and should be used for informational purposes only. We cannot guarantee the accuracy, completeness, or timeliness of the information provided.

Dr. Lisa Damour:
Most of the time when it comes to parenting dilemmas, I think the best thing to do is to trust our instincts. We know our kids better than anyone ever will. We know the context, we know what’s going on. Almost always our instincts are pointing us in the right direction. But you can hear now that I’m coming up on an exception, and that exception is often around anxiety. When our kids are anxious, we often feel anxious too. And when our kid wants to avoid something to bring their anxiety under control, our instincts can suggest that that’s a good idea because we do know it will help them feel better. But on this one, our instincts can lead us astray. Today, I’m joined by Dr. Meredith Elkins, who is a clinical psychologist and faculty member at Harvard Medical School, where her work centers on the research about the treatment of anxiety in children and families.

She’s the co-program director of the McLean Anxiety Mastery Program at McLean Hospital. She’s also the author of Parenting Anxiety: Breaking the Cycle of Worry and Raising Resilient Kids.
Let’s get into it.
Meredith Elkins, thank you so much for being here with me.

Dr. Meredith Elkins:
It’s an absolute delight to be here. Thank you, Lisa.

Dr. Lisa Damour:
Glad to have you. All right, here’s our letter.

“Dear Lisa, my 15-year-old daughter is very anxious about school and hasn’t made a single friend in high school. Her grade school friends drifted away and no longer talk to her. I think that’s actually when her anxiety took hold, almost as if it were protecting her from more rejection. She started ninth grade last year, and for much of it, we had to pick her up at lunch most days because she’d spend that time hiding in the washroom or standing by the door, not eating, not talking to anyone. She’s always been a quiet, introverted girl, but over the past couple of years, she has cried more times than I could count about being left out and over the sheer dread of going to school. I’ve connected with a school social worker who’s willing to work with her, but I don’t think my daughter will open up to her. Here’s what I keep turning over. Is this just a shy, introverted teenager going through a hard, lonely stretch or has it crossed into something that needs clinical treatment? And if it’s the latter, how do I help her when she won’t talk to anyone?”

Okay. Where do you want to start?

Dr. Meredith Elkins:
First of all, my heart just absolutely goes out to this parent who is clearly working so hard for their daughter and their daughter is having such a painful experience. And as much as we’d like to be able to be objective and detached and stalwart when our kids are struggling, there’s no way for it to be completely objective. And so you can hear that this parent is thinking so much about their child and that their child is really struggling. And so I think to answer the parent’s question first and foremost, is this just a kid having a hard time or has this dovetailed into something where more intervention is needed? I would say yes, I would look for intervention for your child at this point and I’ll tell you why. Of course, kids of all ages, but especially teenagers are going to struggle with periods of rejection and to some extent that is just a natural part of development.

But I’m hearing a prolonged period now.

Dr. Lisa Damour:
Okay, this isn’t just a little bump in the road.

Dr. Meredith Elkins:
Yes.

Dr. Lisa Damour:
This is a ditch.

Dr. Meredith Elkins:
Yes, this is an absolute ditch. This is a prolonged period of real isolation where both the teen and her family, their routines are changing. And one of the hallmarks of a clinical anxiety disorder is interference, functional interference. So how much is anxiety getting in the way of life and routine, getting in the way of doing what you need and want to do? So this young person is being picked up halfway through school repeatedly. This isn’t just a one time thing. And so that’s absolutely something that’s going to require some more intervention.

Dr. Lisa Damour:
Okay. We could picture a situation where a kid is coming home saying, “I don’t have friends. I eat lunch alone. I am very sad, but I’m going to class. I’m going to practice. I don’t like this. I am in pain about it.” So then of course the loving parent’s going to be in pain, which as bad as it is, I don’t know that you or I would be like, “That kid needs therapy tomorrow.”

Dr. Meredith Elkins:
Absolutely. I think that’s a really important distinction. I want to back up a little bit because I don’t think that our language is doing us any favors. We have distinct words for sadness and depression, but with anxiety, it’s just all anxiety.

Dr. Lisa Damour:
We messed this up so much. No, we really did. I mean, we psychologists, we clinicians.

Dr. Meredith Elkins:
We had the chance. We had the chance to do something and to create the vocabulary to distinguish this and we didn’t.

Dr. Lisa Damour:
I have grappled this- with this myself, so I’m like, there’s nerves and there’s anxiety, but I do think it is terrible. I will happily take all the blame for this personally, that we have anxiety disorders and then anxiety is something that we just talk about in a garden variety way. So let’s actually go deeper there. So what is the difference between nerves that are not that fun and an anxiety disorder?

Dr. Meredith Elkins:
I’m so glad to get the chance to do this because I think that because we use the same term anxiety for both clinical anxiety and the normative, natural, painful emotional experience that we all have, it has the effect of both flattening everything and also over-pathologizing everything.

Dr. Lisa Damour:
That’s true. Everything’s pathological or nothing is pathological.

Dr. Meredith Elkins:
Right, exactly.

Dr. Lisa Damour:
When in fact we have a pretty clear sense of this as a field.

Dr. Meredith Elkins:
Absolutely. Absolutely. There’s no spit test for an anxiety disorder.

Dr. Lisa Damour:
There’s no blood test you can take.

Dr. Meredith Elkins:
There’s no blood test, there’s no swab because it is a continuum. So we are trying to make a binary out of something that’s a continuum. I like to think about the metaphor of a glass of drinking water for anxiety. We all come into the world with some water in our glass and an over- because of our genetic inheritance. When the glass is kind of overflowing, that might be a clinical anxiety disorder.

Dr. Lisa Damour:
So some anxiety water for everybody.

Dr. Meredith Elkins:
Everybody’s got it.

Dr. Lisa Damour:
So that we also stay safe and don’t run into traffic.

Dr. Meredith Elkins:
Absolutely.

Dr. Lisa Damour:
That it actually has this functional role.

Dr. Meredith Elkins:
Exactly. As nice as it would be to be like, “My anxiety glass is totally empty.” No, when we would die because we wouldn’t look both ways before we crossed the street, we wouldn’t brush our teeth before a date, right? There are all these reasons that anxiety –

Dr. Lisa Damour:
Which is worse.

Dr. Meredith Elkins:
It’s dicey, but anxiety keeps us safe. And I think when we fall into the trap of over pathologizing anxiety, then every painful emotional experience becomes a crisis that we think requires intervention. And that’s not the case with so many kids and adults alike. That doesn’t mean that normative anxiety isn’t painful or worthy of empathy and attention by parents, but it does mean that it doesn’t need to be a crisis.

Dr. Lisa Damour:
I love that. And I’m actually kind of still stuck on your point of when we mix these up, we both over correct and under correct. Okay. So this child needs to be seen clinically.

Dr. Meredith Elkins:
This child needs to be seen clinically. And the reason that we know that doing so isn’t over-pathologizing or over-correcting is because we’re seeing three indicators that clinicians like us use to distinguish whether or not this is normative anxiety or clinical anxiety. So I already mentioned the first one is interference. So how much is anxiety getting in the way of day-to-day life? I can imagine that this is requiring parents or other caregivers to pick her up from school. That can be disruptive to the responsibilities that they have to do and the other family members need to be doing. It’s certainly disruptive to her education as well.

Dr. Lisa Damour:
I mean, leaving school halfway through the day in high school.

Dr. Meredith Elkins:
You’re missing a lot.

Dr. Lisa Damour:
Oh my gosh.

Dr. Meredith Elkins:
Right.

Dr. Lisa Damour:
Yeah.

Dr. Meredith Elkins:
And it becomes a self-reinforcing challenge because then she has less opportunities to make friends because she’s not there. So we see some real functional interference here. The other piece is distress. This is a kid who is articulating how alone that she is.

Dr. Lisa Damour:
I mean, she’s crying.

Dr. Meredith Elkins:
She’s crying.

Dr. Lisa Damour:
She isn’t sleeping. She is in so much pain.

Dr. Meredith Elkins:
Right. This is not a preference, right?

Dr. Lisa Damour:
Right. This isn’t, “I wish I had more people to hang out with.” This is, “I am really, really suffering in the face of this.”

Dr. Meredith Elkins:
Right. So the distress is palpable. It’s acute. And then number three, this has lasted for a while, right? This is not, “My friends ditched me and I’ve got a two week period where everything feels awful and then I get re-engaged and I recover and I make new friends.”

Dr. Lisa Damour:
“Go hang out with the kids I wasn’t planning to hang out with-”

Dr. Meredith Elkins:
“But now they can be my people too.” Right?

So this has all three markers, interference, duration, and distress. And so those are the hallmarks of why I think that this child does need intervention. I don’t think this is just a phase that we’re over pathologizing, and I think the parent is right to be looking into that.

Dr. Lisa Damour:
Okay. So you mentioned the continuum. So on the continuum, this kid’s easy in some ways. This is definitely get help. The other continuum of anxiety is a kid who isn’t actually all that anxious about a lot of things and maybe should be a little more anxious at times and probably loves X games and likes things that are really thrilling because they have pretty low anxiety and that’s how they’re wired. Thinking about it again, I feel like the kid I mentioned to you is kind of in a gray zone, right? The kid I invented. So wishes they had more friends, eats lunch alone, is coming home saying… And let’s put some anxiety there. “I don’t know how to talk to people. I’m worried if I reach out that I’m going to be rejected, so I stay to myself.” So kind of more in that social anxiety neighborhood and yet functioning is in place.

Dr. Meredith Elkins:
Distress is sort of mild.

Dr. Lisa Damour:
Distress is not super acute. But maybe it’s been going on a while, right? If you’re not eating lunch with anybody over time, as somebody who just like, we love kids, we love kids in school, that’s a pretty painful thing to see. What would you recommend for that kid that I just made up?

Dr. Meredith Elkins:
Yeah. Well, that kid definitely exists, right? And we see the gray zone so often. I think this is why it can be tough to put a binary on the continuum, but I think one of the really powerful things about what we know about anxiety and its treatment is that the best ways to address anxiety, whether it is normative anxiety, gray area anxiety, or clinical anxiety, is that it’s the same framework.

Dr. Lisa Damour:
Okay.

Dr. Meredith Elkins:
So we can help kids in the gray zone feel better in terms of their anxiety by doing many of the same things that we would do with the young person with clinical anxiety. I feel like that’s a game changer, right? It’s not either like do they need a medication or we’re not going to touch them. It’s like as parents, we can start encouraging both of these kids to do some of the evidence-based approaches to anxiety management that we know work.

Dr. Lisa Damour:
Okay. Did you ever see the movie My Big Fat Greek Wedding?

Dr. Meredith Elkins:
Yes, we owned it. We definitely owned it in DVD format. Yes, yes. I’m intimately familiar with this.

Dr. Lisa Damour:
I’ve never thought about it this way before, but I think you’re going to be with me.

Dr. Meredith Elkins:
Okay.

Dr. Lisa Damour:
You know how the dad is like, “Put Windex on it”?

Dr. Meredith Elkins:
“Put Windex on.”

Dr. Lisa Damour:
“Put Windex on.” Right? Like, “I’ve got a pimple,” “Put Windex on it.”

I think we kind of get to do that in the treatment of anxiety. We’ve got Windex.

Dr. Meredith Elkins:
This is my favorite thing now, that exposure based treatments are the Windex.

Dr. Lisa Damour:
So we got Windex.

Dr. Meredith Elkins:
Let’s talk about it.

Dr. Lisa Damour:
And anyone who’s listening who’s not seen the Big Fat Greek Wedding, should go see it. It’s fun.

Dr. Meredith Elkins:
Go see it.
It’s an American class.

Dr. Lisa Damour:
It’s great. Okay.

So what’s the Windex? And we just do more or less Windex, right? Different kinds –

Dr. Meredith Elkins:
Right and who does the Windex?

Dr. Lisa Damour:
Okay. Walk us through Windex.

Dr. Meredith Elkins:
All right. So we know that the gold standard treatment, psychological treatment for anxiety disorders across the lifespan are exposure-based therapies. So what is exposure? Exposure is effectively doing hard things and it is –

Dr. Lisa Damour:
Doing the things we really don’t want to do.

Dr. Meredith Elkins:
Doing the things we don’t want to do, right?

Dr. Lisa Damour:
Yeah.

Dr. Meredith Elkins:
But it is predicated on the understanding that the more we avoid something that causes us distress and anxiety, the worse anxiety becomes. And that happens for, I think, a reason that we can all sort of understand when we look back at our own lives. So when we avoid something that feels uncomfortable in the moment, the relief is just immediate –

Dr. Lisa Damour:
It’s like a glass of wine.

Dr. Meredith Elkins:
Immemorable, right? It’s just, yes, if you are about to send an email that you have been dreading and then you get called into a meeting, you’re like, “Yes, I will take that meeting,” because you got to avoid the thing that was causing you discomfort. But when we avoid, we teach ourselves something, right? The brain learns something really powerful there. It learns that the only reason we felt better was because we escaped the challenging thing, and that leads to a belief that we couldn’t have handled that challenging thing.

And so while we feel better in the moment, the next time we have to engage with a similar situation, our anxiety is actually going to be more intense, and then we’re more likely to avoid again.

Dr. Lisa Damour:
And the brain’s like, “I know what works really in these situations.”

Dr. Meredith Elkins:
“I know what works great for you.”

Dr. Lisa Damour:
Let’s get out of here.

Dr. Meredith Elkins:
And so you can think of this young person, she’s feeling really anxious and deeply alone at school, and so she goes to the bathroom, texts parents, they come pick her up. That relief is just immediate and memorable and sticks with her. And it’s leading to the sense of, “I am deeply alone. I am unlovable. I am incapable of making friends,” which makes it more likely that when that icky feeling comes up the next day, she’s going to avoid again.

Dr. Lisa Damour:
Back to the bathroom.

Dr. Meredith Elkins:
Right, exactly. So we know that avoidance fuels anxiety. So what is the antidote to that? It’s not fun and it’s not easy, but in many ways it is effective because it’s not fun and because it’s not easy. So what we want to start doing is turning the avoidance on its head by engaging in exposure work. So we are going to gradually start engaging in the situations that make us feel uncomfortable. And we can do it in… You don’t have to like, “Okay, she’s in school for the full day for forever.”

Dr. Lisa Damour:
“Deep end. Dive in.”

Dr. Meredith Elkins:
We don’t need to push her into the deep end, but if this were a child that I was working with, we would be starting to figure out, “Okay, so what are the situations that actually make you feeling the most uncomfortable? We’re going to rank them from least distressing to most distressing, and we’re going to start with the low hanging fruit. So could it be saying hi to a peer in the classroom might be just one task that you have to do today, and we’re going to start gradually building up from there.” And what this does is it’s very akin to a new exercise routine. When you first start exercising and you feel it the next day, you know that you are building muscle, you’re doing something hard. If it’s a blip on the radar and you go back home and you’re eating Cheetos, that’s not going to do anything for your muscles, but you’re going to feel better, right?

I joke with families who come into the program that I help run that I wish we were a spa. We’re not a spa. You’re actually probably going to feel more anxious when we get started because we’re doing exactly what we’re supposed to be doing. We’re leaning into anxiety instead of away from it.

Dr. Lisa Damour:
Okay. So where there’s problematic anxiety, there’s always avoidance and the solution truly always is to tackle the avoidance. Okay.

You touched on it. I want to return to it. This parent must be feeling awful. And it’s actually sort of staggering to me in the letters that we get that parents seem to find a way to put that to the side to write such a beautiful description of what their kid is going through. And you heard it and I read it and we’re like, “Oh my gosh, this parent, the idea that this is happening to one’s kid, the idea that your kid is in this much pain, stomach turning, right? Stomach turning.” So then how do you talk families into making their kid feel worse on the way to getting better? If we’re already at this point of just intolerable pain for the child and the parent, and then you’re like, “Welcome to my clinic.” We’re going to make you all feel worse.

How do you help people withstand that?

Dr. Meredith Elkins:
It’s a really good question, and I think this is where helping families, both the parent and the child, identify their values and their goals is such a crucial part of this work. We already know from what this parent shared with us that this is a young person who wants a social life, who wants friends and feels like it’s unattainable for her.

Dr. Lisa Damour:
Longing for it.

Dr. Meredith Elkins:
Longing for it.

Dr. Lisa Damour:
At least she’s sad about it.

Dr. Meredith Elkins:
Yes.

Dr. Lisa Damour:
In some ways, we hate that she’s sad, but we’re so glad she’s sad.

Dr. Meredith Elkins:
Right.

Dr. Lisa Damour:
Because that gives you some leverage or something to work with.

Dr. Meredith Elkins:
Exactly. So what do you want your life to look like? Where is your life now versus what you want it to look like? And what have you been trying so far and how has it worked? I would hazard a guess that particularly in the course of working with this young person, building rapport, that she would be able to articulate like, “What I’m doing right now isn’t working. Going to the bathroom is not working for me. It’s not making things better.” Might take some time.

Dr. Lisa Damour:
We all have our lines, like our clinical lines. You just basically said my favorite one, which is when… Usually it comes up in the context of a family will come in and they’ll be like, “And then we did this and then we did this and we did this.” And they’re really trying. And I’ll say, “And what you’re doing isn’t working.” And it matters to me to say it though because I see that you’re doing all these things. It’s not working.

Dr. Meredith Elkins:
And if it were just about effort, you would be there.

Dr. Lisa Damour:
You would be there, but it’s not working.

Dr. Meredith Elkins:
It’s not working.

Dr. Lisa Damour:
So we have to try something else.

Dr. Meredith Elkins:
Right.

Dr. Lisa Damour:
Okay.

Dr. Meredith Elkins:
Right. “Are you willing to kind of get messy with me?”

Dr. Lisa Damour:
Okay. Okay. So you lay it out pretty clearly. “What you’re doing isn’t working. You’ve landed in my office, not where anybody wants to be. To get you out of this, it’s going to get messy.” Do you say messy?

Dr. Meredith Elkins:
Yeah. I think it’s going to get messy. It’s going to be challenging, but I also love to pull on parent and child experience. So everyone has had something they’ve done in their life that has been challenging, that has been hard. When we think back at the most formative experiences of our lives, it’s usually when something went off the rails and we sort of surprised ourselves and we rose to the occasion and we dealt with a challenge. It wasn’t when our parents swooped in and found us a new best friend.

Dr. Lisa Damour:
Right.

Dr. Meredith Elkins:
Right.

Dr. Lisa Damour:
It’s like we toughed it out. We found our way.

Dr. Meredith Elkins:
Exactly. Exactly. And so I think that one, we can pull on the child’s own experience to be like, “Let’s find something where you have evidence of your own capability.”

Dr. Lisa Damour:
Which is also saying, “You’ve done this before. I’m not asking you to do something you’ve never done in your life.”

Dr. Meredith Elkins:
Right. And I also think that it can be so helpful to normalize the experience of, it’s not just like, “You’re in a really bad state, so we need to do this in intensive exposure therapy, like buckle up buttercup.”

But I think that we can… I often do share kind of stories from my own life or my experience. And one thing about going to graduate school in a city for a long time is that you don’t have to drive. Between being in Boston and being in Manhattan for almost a decade, I didn’t have to drive for a really long time. So I wasn’t trying to avoid driving, but I was functionally avoiding driving, right? So by the time I was in a position in life where I actually had to get behind the wheel of the car, I was pregnant and terrified to operate a vehicle.

Dr. Lisa Damour:
And badly out of practice.

Dr. Meredith Elkins:
Badly out of practice and driving in Massachusetts, which if any –

Dr. Lisa Damour:
Oh, I actually find terrifying.

Dr. Meredith Elkins:
Yeah.

Dr. Lisa Damour:
I find Boston driving –

Dr. Meredith Elkins:
Just objectively terrifying.

Dr. Lisa Damour:
Yeah, no, like Uber for me. Yeah.

Dr. Meredith Elkins:
So again, I wasn’t looking to give myself an anxiety about driving, but it just happened because of avoidance. And so what do you do with that? And so especially teenagers who are driving or getting on the verge of driving, they know you have to practice, right? You have to get yourself into that car while you’re carrying your unborn baby and afraid you’re going to crash everything, and you just have to do it. And when you do it over and over again, you effectively get bored. So I do think –

Dr. Lisa Damour:
Wait, you say that fast. That’s important. That’s important. You’re going to do this till you’re bored.

Dr. Meredith Elkins:
You’re going to do this until you’re bored, until it doesn’t increase your anxiety anymore. When we think about things that were hard that are now no longer hard, they’re kind of boring.

Dr. Lisa Damour:
When you throw that out, it’s so clever because you’re actually saying the destination is well within the human repertoire and well within your repertoire. The destination, you’ve been there before on other things. I’m not promising you anything that is unfamiliar, but to get to that very boring destination, you’re going to get uncomfortable for a little while, like we all have to do when we have to get back in the saddle on something.

Dr. Meredith Elkins:
Absolutely. And again, I think parents have lived experience with this. Most kids, even little kids have lived experience with this, like learning piano and how much harder it was at the start where it is now. And so the idea of practicing something and getting better, I think can help to normalize this experience. And frankly, anything that we do that is values oriented and challenging is an exposure. So we’re all doing exposures all the time.

Dr. Lisa Damour:
Give me another for instance.

Dr. Meredith Elkins:
So if you have to give a presentation for work or for school and you notice a little bit of discomfort, but you don’t call out sick, right? That’s an exposure.

Dr. Lisa Damour:
Okay. So that’s values oriented. It matters to me to do this and it is hard. I did it anyway. It’s an exposure. And what you’re giving us also is, even though you and I are talking shop clinically, do use all these things at home. This is all DIY. This is all language at home. “I didn’t want to give the presentation I gave at work today and yet I gave it. You don’t want to go call that person and make that appointment and yet you’re going to do it.” We are always doing exposure. We are, our kids are, we can talk about it that way.

Dr. Meredith Elkins:
I think that this is such an opportunity for parents to model effective coping with anxiety. If you as a parent are the calm, cool, collected, blank slate and you’re never articulating like, “I have a presentation I got to give today. I’m nervous about it and I’m going to get my pants on and we’re going to go do it.” Then what are you showing your kid then that you can experience anxiety and still rise to the occasion rather than, “My parents are inflappable and so something is wrong with me that I am not.”

Dr. Lisa Damour:
So sort of being open about those experiences has huge value.

Dr. Meredith Elkins:
Has huge value. And so I think so often, because our parenting culture expects and demands so much of us, I think parents are sometimes hesitant to communicate to their children that they feel anxious, that we feel anxious sometimes. And so I think that this is a really powerful intervention and especially for a young person like this who feels so deeply alone and probably feels so broken when she compares herself to her peers and she doesn’t have close friends, so she doesn’t see that everybody else is anxious too and that there’s so much more common ground. So I would say to this parent, modeling in a developmentally appropriate way, the challenges that we as parents have with anxiety can help a kid feel less alone.

So many families, I’m sure you experience the same thing, they come in and you say, “What do you want from treatment?” And they said, “I want my kid to be confident,” but there’s no confidence pill.

There’s no hack for that, right? Confidence is earned over time by doing hard things, which again is what exposure is. So whether it’s in the service of addressing a clinical anxiety presentation directly targeting social anxiety or whether it’s helping kids build mastery for doing things that feel uncomfortable, whether it’s changing a tire or whether it’s initiating a group text when they’re like, “Nobody’s going to want to do that.” That comfortable level of discomfort, that is the sweet spot for growth. Any teacher will tell you that, right? Discomfort is where the learning happens.

Dr. Lisa Damour:
Grappling.

Dr. Meredith Elkins:
Yes.

Dr. Lisa Damour:
Grappling is the language I love in the literature. Only when you’re grappling are you learning.

Dr. Meredith Elkins:
Exactly.

Dr. Lisa Damour:
Okay. This kid’s not going to talk to anybody. This mom’s like, “Okay, you’re offering to make it worse and my kid’s already not talking to anybody. And why would we do this and how are we going to do this? And this is not going to work.” Okay.

Dr. Meredith Elkins:
So I would just caveat the assumption that this child will not talk to anybody. Perhaps, I mean, again, this parent knows their child better than I ever would presume to, even if we were meeting in person. And kids can surprise you, right? So sometimes I think we make parenting choices based on what we assume our kids will or won’t do, and we can be surprised. So we know that rapport, strong therapeutic rapport accounts for as much as 50% of clinical outcomes. So even if it’s not going to be a great fit with the school personnel who the parent identified, is there somebody else who this young person might talk to? So I wouldn’t write it off entirely, but I will say that one of the most empowering and hopeful developments in the field in the past 10, 15 years has been the development of parent focused treatments for child anxiety.

So Ellie Lebowitz at Yale Child Studies Center –

Dr. Lisa Damour:
This is the SPACE work.

Dr. Meredith Elkins:
The SPACE program, yes.

Dr. Lisa Damour:
Yeah, which is not a space program in terms of –

Dr. Meredith Elkins:
We’re not talking Mars.

Dr. Lisa Damour:
We’re not talking Mars. What does this stand for?

Dr. Meredith Elkins:
Supportive Parenting for Anxious Childhood Emotions.

Dr. Lisa Damour:
Okay, nice. Okay. So this is game changing?

Dr. Meredith Elkins:
Yes, this is game changing because… So what this does, the child is the patient. The therapist does not primarily meet with the child. They primarily meet with the parents. And by working with the parents to figure out how are the parents responding to the child’s anxiety, and in what ways is that actually well-intentioned accommodation that’s reinforcing the cycle? An accommodation –

Dr. Lisa Damour:
Is the magic word.

Dr. Meredith Elkins:
Is the magic word, and it means so many different things in so many different contexts. But in this context, an accommodation is a change that we make to our own behavior to reduce the distress of somebody else. And so this is… I mean, I accommodate my kid all the time.This is a normal parent. I accommodate my husband all the time. I accommodate the dog all the time.

Dr. Lisa Damour:
Because I have to live with them.

Dr. Meredith Elkins:
Because you have to live with them.

Dr. Lisa Damour:
And I like them, but also because I have to live with them.

Dr. Meredith Elkins:
Right. Right. Accommodation is not like a black letter thing where this is an abnormal thing and anytime you’re accommodating your kid, Meredith and Lisa say no. That’s not what I’m saying. In what way are the parents, in a loving way, that’s attempting to decrease the child distress, inadvertently reinforcing the anxiety?

Dr. Lisa Damour:
Okay. This is the key. Say it again.

Dr. Meredith Elkins:
So the challenge is for parents to think about how they are responding to their child’s behavior that is accidentally reinforcing the anxiety.

Dr. Lisa Damour:
Okay. Well intentioned, accidental, making it worse.

Dr. Meredith Elkins:
Right. No parent on earth is like, “You know what? How can we fuel the fire today? How can we build onto the anxiety?” But anxiety actually hijacks our deep loving parental instincts to decrease the distress of our children and makes it more likely that this avoidance cycle is going to continue. And this is the crux of the space-based treatment and other parent-based approaches to anxiety, helping parents to recognize patterns of accommodation that are not serving their child or themselves well. I mean, the research shows that parents don’t like accommodating either. Not only do parents who accommodate kids have kids with more severe anxiety disorders, but parents who are accommodating their kids more are more depressed and anxious and stressed themselves. So it’s bad news for everyone, and we’re doing it in the service of short-term relief, and because we’re told that this is what love looks like.

Dr. Lisa Damour:
And because our kid does feel better.

Dr. Meredith Elkins:
And because our kid feels better when you pick them up.

Dr. Lisa Damour:
On a given day, it is working.

Dr. Meredith Elkins:
Right.

Dr. Lisa Damour:
It is working.

Dr. Meredith Elkins:
And this is why it’s so hard, because you are in the parent role. Not only are you seeing your child as an absolute puddle, begging you to come intervene and do the quick fix for them, but your anxiety is naturally high because your child’s distress is high, and you’re questioning whether you’re doing the good parent thing if you say, “You know what? We’re going to set a limit around how much space anxiety is going to take up in our home.” When parents start reducing accommodation, you are going to feel like a dumpster parent.

Dr. Lisa Damour:
You feel like the worst parent in the world.

Dr. Meredith Elkins:
Yeah.

Dr. Lisa Damour:
Okay.

Dr. Meredith Elkins:
But good parenting feels bad sometimes. Think about how when you took your kids to get their first shots and the doctor or the nurse stuck the needle in those chubby little thighs and you cried and they cried and you did that not because you were like, “Yes, please put my infant in pain,” but because you knew it was going to confer long-term benefit.

Dr. Lisa Damour:
Good parenting feels bad sometimes.

Dr. Meredith Elkins:
Good parenting feels bad sometimes.

Dr. Lisa Damour:
I will tell you what it just rocketed me back to. I remember when my older daughter was a toddler, sometimes from her crib, she would in the middle of the night be like, “I’m hungry.” Even though I knew she wasn’t hungry, but she wanted me to come get her. And I would cling to my pillow and be like, “Go to sleep. Go to sleep.” I’m like, “What mother tells a child who is calling from their bedroom,” “I’m hungry.” “Go to sleep, go to sleep.” I was like,” I don’t think she’s hungry. I really don’t think she’s hungry. She’s super clever. She knows this is such a button.” And I was literally in my room, I remember this clinging to my pillow thinking, “If I reinforce this tonight, we’re in this for the long haul.”

Dr. Meredith Elkins:
Right. 100%. And you said, “What parent doesn’t go feed their child?” And I’m like, I’ll tell you what parents, Boomers. Boomers didn’t do this. And I think that in our attempt to be more emotionally present and aware with our children, to give them that warmth that was sometimes absent in different generations of parenting, we are saying that our child’s distress in whatever form, whether it’s the middle of the night I want a banana or whether it’s pick me up from school now, is a crisis that we have to fix in order to be a good parent. And this is such, such a hard situation for parents to be navigating. But it’s why I think doing this for kids with clinical anxiety disorders, doing this with a therapist who can help guide you to reduce accommodations gradually, planfully with your child’s awareness that it’s going to be happening and understanding why, that’s different from ripping the rug.

Dr. Lisa Damour:
This doesn’t have to be cruel.

Dr. Meredith Elkins:
Right. It is not cruel.

Dr. Lisa Damour:
And all the while, we’re giving kids ways to better manage their anxiety and teaching them breathing. And this is not like, let’s just make you tough us out, Cookie. We are kind, but a lot of this you can do at home and probably a lot of this you can do at home with the gray area kids. But if it gets to the place that this is, if you’re in a ditch, get yourself someone who really can do it in a kind way because what has to happen is not going to be easy and is not going to be fun, but it doesn’t have to be cruel.

Dr. Meredith Elkins:
Right. And I do think that there is a lot to be said for these parents. Let’s say the daughter will not engage with a therapist saying, “We love you too much to let anxiety rule the rest of your life. So if it doesn’t feel accessible for you to meet with a provider right now, we’re going to, and we are going to make some changes to how we respond because we care enough to not let anxiety run your life. And if you want to get on board, if you want to come on in and start doing this work, having more ownership over it in your own therapy, great.”

And often, especially with really entrenched and interfering anxiety, if circumstances allow, having the child do their own exposure work and also learning their cognitive coping strategies, their mindfulness strategies, their toolkit for managing anxiety on their own while the parent is also learning how they can respond to these high intensity anxiety moments and treat their own distress and anxiety, that’s the unicorn.

Dr. Lisa Damour:
That’s sort of the gold standard if we could do it all.

Dr. Meredith Elkins:
Absolutely.

Dr. Lisa Damour:
Let me ask you this. I don’t think this is the case with this particular letter, but how does a family know when it’s time to be like, “You know what? This kid needs a new school. It’s not the kid, it’s the school. We got to change schools.”

Dr. Meredith Elkins:
This is such a common question and frankly, it makes so much sense, especially if this kid is just being left out constantly. Of course, when parents are running through all of the options, school change is probably one of the considerations depending on feasibility. I’m always really cautious about this because we know that anxiety is an opportunist and anxiety sees the opportunity here with this young person to kind of wreck lives and make them leave school early. Generally we find that without treating the underlying anxiety, whatever is going on for this young person that leads to this rise of distress in the moment, that urge to pull the escape hatch, call the parents for the accommodation and be picked up without addressing that cycle, I’m not a betting woman, but I would bet that in the next school or in a future iteration that escape will be the go-to coping strategy because it’s so effective.

So unless there is something where there is real sustained bullying, harassment, discrimination, a challenge to a child’s safety, I would not want to encourage parents to pull the child without making a really good faith effort to address the underlying anxiety and the accommodation cycles within the home.

Dr. Lisa Damour:
You know what it reminds me of is a phrase I’ve sometimes heard loving adults say to kids who want to blame the situation is, “Don’t forget, you take yourself everywhere you go.”

Dr. Meredith Elkins:
I love that.

Dr. Lisa Damour:
“That you own a piece of this and you’re going to want to be in charge of that piece.”

Dr. Meredith Elkins:
Absolutely. And I think that that’s so, so important. But again, so much anxiety sucks agency from all of us. And so being able to help kids and parents feel like they are meaningful contributors to their own emotional outcome rather than it being situationally dependent is such a powerful lesson.

Dr. Lisa Damour:
All right. As we wrap this up, what are the headlines? What are the big ideas? What’s the takeaway here?

Dr. Meredith Elkins:
I think the takeaway for the parent is that your instincts are right, that this is not just teenage isolation, that this is now the kind of clinical anxiety disorder arena. And there’s so much reason to be optimistic. Anxiety disorders are the most common class of mental health conditions, which means that there’s a ton of research on them. We understand them very well. We know how to treat this.

Dr. Lisa Damour:
100%.

Dr. Meredith Elkins:
And so even if your child won’t go to therapy, you are not powerless. There are still ways that you can change how you respond to your daughter’s anxiety that can help push her in the right direction, lovingly, but with the commitment that anxiety cannot drive the bus for the rest of her life. And I think that that’s such a powerful, powerful message for parents to be able to give their kids.

Dr. Lisa Damour:
Anxiety doesn’t get to be in charge.

Dr. Meredith Elkins:
It doesn’t get to be.

Dr. Lisa Damour:
Dr. Elkins, thank you so much for being here.

Dr. Meredith Elkins:
It’s truly my pleasure.

Dr. Lisa Damour:
For Parenting to Go today, I want to return to the idea of exposure, not accommodation, which of course is Dr. Elkins’ recommendation anytime we’re dealing with anxiety. And the thing I want to underscore here is we have total consensus on this in the field of clinical care, and this is very rare. Most of the time around things that kids struggle with, there are a lot of perspectives and a lot of ideas about how best to take care of something. When it comes to anxiety, we have very rare consensus in the field. The principles of anxiety are very clearly understood and what treats it best is also clearly understood. So as much as it’s no fun to have a kid who’s anxious or to feel anxious ourselves, I think there’s something wonderfully reassuring when we get to the question of anxiety, which is basically, “We got Windex.”

We know what works. And when it comes to anxiety, what always works to make it better is exposure and what always works to make it worse is accommodation.
And next week, join me for an Office Hours episode where I take your questions and I answer them. This Office Hours is going to be, What To Do When Our Tweens And Teens Are Not Entirely Honest With Us. I’ll see you next week.

Thanks for joining us. Be sure to subscribe to the Ask Lisa Podcast so you get episodes just as soon as they drop and send us your questions to [email protected]. And now a word from our lawyers.

The information provided on this podcast is for educational purposes only and does not constitute or substitute for professional psychological treatment, therapy, medical advice, or other professional intervention. Views expressed by guests are their own and do not necessarily reflect the views of Dr. Lisa Damoure or Ask Lisa. If you have concerns about your child’s wellbeing or your own, please consult a physician or mental health professional.

If you or someone you know is in crisis, contact the 988 Suicide and Crisis Lifeline by calling or texting 988. For additional resources, visit drlisadamour.com.