On January 25th, Fusion Academy Mission Viejo hosted a screening of the documentary Angst which addresses anxiety and the issues surrounding it. After the screening, Dr. Jamie Lesser, Dr. Curtis Hsia, and Jackie Jarrard-Turner participated in a panel discussion and Q&A, which is transcribed below.
Are you seeing a greater prevalence of anxiety and depression now than there was 10 years ago or a generation ago, and if so, what’s the cause?
There’s more awareness of being diagnosed now, but it’s still stigmatized. Although, to a lesser degree. That awareness could account for seeming like there’s more.
It varies a little bit but the rate isn’t increasing. We see more openness and discussion on the topic, but the actual rates are about the same.
There’s more visibility because of social media. It’s talked about on reality TV and people post about it on Facebook and Instagram, so teens feel more comfortable talking about it in general.
What do you recommend to parents do to help manage their kid’s phone and social media usage and access?
We definitely think it’s a case by case basis, but at the same time, if you’re going to talk about in terms of anxiety, that there’s a lot of forces in social media and with the internet that can contribute negatively to kids who already experience anxiety. It would be safe to consider that social media/internet is probably a contributing factor; just have a dialogue with your kid, and if you’re working with professionals, try to get to the bottom of what would work best for your kid in that situation. Also, not having access to friends can contribute to anxiety, so it really comes down to exploring the particular situation.
It’s important for professionals to collaborate with parents in order to adhere to a set of rules and consequences for students that require that kind of structure due to behavioral issues. All parents involved need to participate equally as well. I had a student whose mom took the phone away for two days but the father handed a phone to the student and said, “Here, you might need this at school.” The student now knows how to avoid consequences. So we need to make sure that parenting in is part of the solution and is shared equally by the parents.
Social media exposes children to information at a rate that is overwhelming. How do we initiate conversations with them in order to help them realize that they need to slow down and get away from it for a while?
I would ask, “How does this make you feel?” Children need to develop the ability to analyze their own feelings and reactions to the things they encounter rather than simply coming up with a plan to use social media less often. There needs to be a more explorative conversation. Ask the questions, “How does this affect your studying?” “How does this make you feel?” “How does this affect your time with family?”
If you’re the parent, it’s useful to start by using yourself as an example to establish a level of empathy. I would tell my girls that I didn’t grow up with phones and social media. I’ve only been using them for maybe ten years, but I struggle with them as a distraction too because it’s difficult to navigate how to use them properly. Then, there’s a dialogue between me and my daughters which allows them to get involved in the conversation and begin to self-reflect.
Part of the video said that parents shouldn’t be aiding and abetting and you were just talking about making sure you have the right tools. So, as a parent, where do you recommend that I start? What resources are available so I can start finding those tools?
It depends on the issue. If it’s for anxiety, you can visit www.adaa.org. If it’s for OCD, you can visit www.iocd.org. These are a couple good resources to help begin your search.
I recommend a children’s book called “Sitting Still like a Frog”. It’s about teaching mindfulness to very young children but I use it for teenager and adults too because it’s very simplified and accessible. I know the idea of having teenagers read a children’s book may seem silly, but I think teenagers sometimes want to feel like kids again so they might enjoy reading it to escape the pressure of needing to be an adult.
Simple breathing exercises work well. There’s an app called Headspace that helps guide your breathing by taking it step by step. Some people love it.
SSRIs seem to be a common tool used to deal with anxiety. Our daughter was taking them but then decided to stop for a while. It wasn’t long before her symptoms returned. So, I’m curious, even though I know you all aren’t psychiatrists, what are your thoughts on that?
SSRIs are often used for both anxiety and depression and have varying effects. It depends on the situation. SSRIs are used most effectively as a way of curbing anxiety to make learning CBT techniques easier. That way, a person can stop taking SSRIs but have the ability to control their anxiety as it begins to build again, if and when it does.
Certain disorders require a certain level of care. For example, there’s a lot of literature available for people with depression that can inform them and help them to decide to begin, end, or continue the use of SSRIs. CBT has been shown to produce better outcomes when used in conjunction with medication.
What is CBT?
There are different approaches to treatment. When we talk about Cognitive Behavioral Therapy (CBT), it’s about changing thoughts and changing behaviors in the current realm. It’s much more research-focused and research-based so there’s a lot of supportive data. For instance, if someone is very fearful of dogs, their behavior will change based on the presence or even the idea of the presence of a dog. CBT attempts to change that behavior by changing that person’s perceived risk of dogs. This is where exposure comes into play – gradually increasing the intensity of exposure, maybe from a picture of a dog, to a video to a dog, to a dog park, helps facilitate that change.
CBT is also more skill-based. It’s about teaching the skills that enable a person to have a more adaptive way of thinking and doing so that they don’t need therapy anymore. It’s a very empowering collaborative approach. Also, there’s often homework which helps keep the person engaged in their own treatment goals.
A good mark for CBT is homework. It’s also a relatively short-term treatment that can be mapped out to last a specific number of sessions. It isn’t meant to be a lifelong endeavor.
Can you explain the relationship between anxiety and depression, because they are often mentioned together?
Typically, anxiety precedes depression. For example, if someone is anxious about a situation and chooses to avoid it, they might regret that decision afterward which can lead to self-critical thoughts. Self-critical thoughts might cause that person to feel anxious about future situations and that anxiety might cause them to choose to avoid those situations as well, causing more self-critical thoughts, and so on. That cycle can lead to depression. To combat that cycle, the film discusses intentional exposure to the things that cause these reactions as a way to help learn how to deal with them.
A lot of times, depression is secondary to anxiety and so I don’t treat the depression. By the time the person is able to manage their anxiety, depression falls off as a result because they’re beginning to have positive interactions with other people again.
Anxiety is an underlying element of many different diagnoses. In the movie, the girl talks about developing eating issues that stemmed from a need to control that stemmed from anxiety. That’s a good example of how anxiety is at the core of a lot of negative symptoms that people experience.
What’s the difference between social anxiety and just being anxious?
Social anxiety is just anxiety in the context of social situations. It’s often related to a fear of rejection or negative evaluation. So, it’s just anxiety that’s contextualized.
One thing the video attempted to do, which is difficult, is talk about anxiety as a whole. Anxiety can be the result of something specific, be it social situations, flying, or dogs. Each source is handled differently based on multiple factors. So, we need to make sure we tailor treatment to the individual to be as effective as possible.
It’s clear when someone with high anxiety needs help, but what does it look like when kids have moderate anxiety? How do we address that?
A lot of kids that see me have parents who want to know if their kid has ADHD. One of the symptoms of anxiety is difficulty concentrating and when a kid has trouble focusing, it can be because of anxious thoughts, not ADHD. Kids who are anxious in class have trouble listening to the teacher and absorbing the content because they’re in their own heads.
Sometimes I’ll look at anxiety in terms of interference or distress in someone’s life. I had a person who was afraid of clowns, for example. She had kids too and they had computers with clown icons on them and they would watch kids’ shows that had clowns in them. After a while, the kids started to pick up on her distress over clowns and they started to become distressed about them as well. At that point, she had to consider what her distress was doing to her kids, much like what is discussed in FST, so that she didn’t affect her kids. That doesn’t mean all stress is bad. A moderate level of stress can be productive. If a student has an exam to study for, a student with low-level stress might shrug it off; a student with high-level stress might overreact; a student with moderate level stress might recognize that there are some stakes involved, recognize it’s important to do well, and prepare appropriately.
Normalizing is also important. My opinion is that anxiety is a natural human state. There is always something to think about or prepare for and to view anxiety as something that must be avoided at all costs can turn a natural human state that all people experience into one that carries with it a variety of negative feelings, compounding the problems that anxiety might already be causing someone.
Normalizing is an element of CBT as well. In CBT, anxiety is intentionally heightened to show that it can be a very extreme feeling. However, helping someone develop the tools to deal with stress at that level causes lower levels to feel more manageable. The goal is to help someone be able to function even at high levels of anxiety and stress.
With anxiety, the more you fight it the worse it gets. Recognizing that anxiety is just another emotion keeps it from becoming a monster. Sometimes it does become a monster, and that’s when it’s necessary to develop skills to deal with that, but the default perspective on anxiety is that it’s a single emotion among many.
How can a teenager with social anxiety shift away from negative thoughts to move forward?
Having the ability to predict how you will feel in social situations, coming to terms with those feelings, and mentally preparing for those feelings, as opposed to avoiding them, is a good approach. Also, be objective about evidence from past interactions. Ask how many people actually walked away from you because they were annoyed by you, for example. How often are the teenager’s feelings comporting with the facts? Also, ask how often what the teen is afraid of happening to them happens to others. Is there social anxiety based on evidence or on fear?
There’s a skill called decentering. It helps teenagers to understand that they aren’t the center of attention at all times. In fact, they are most often not the center of attention. Have them ask themselves if they really think that everyone is looking at them, thinking about them, and talking about them when they walk through a mall. Isn’t it more likely that you’re just another person at the mall walking around among others? Have them ask themselves how often they do that to others. It’s much more likely that no one is paying attention to them. There’s an exercise that uses decentering which instructs the teenager to go to a place and try to guess what everyone there is thinking. It usually ends up being that the teenager realizes that it’s impossible that everyone there is thinking about them.
It can be gradual. You don’t need to take someone with social anxiety and throw them into a group of people to speak publicly in front of. Sometimes, identifying the smallest increment toward the ultimate goal and working on that is the most productive thing to do. We call that systematic desensitization. The important thing in doing that isn’t stopping anxious feelings but instead focusing on if the task was completed or not.