Dr. Khanna's Blog
Welcome to my Outsmarting Anxiety blog. I'm Dr. Muniya Khanna. I'm a clinical psychologist with an expertise in CBT for anxiety disorders, OCD, and related disorders. After many years of research and academic writing, I've decided to focus my energy on getting evidence-based treatments and tools for anxiety and OCD to the public.
Decades of research has given us a lot of information on what works and what doesn't - it shouldn't be kept a mystery - you deserve to know everything that I know.
I'll provide answers to the most common questions that kids, parents, and adults have when they are looking for answers on how to reduce anxiety and stress in their lives. Send questions back to me and I'll create new posts and do my best to give you the answers you are looking for - and if I don't know it myself, I'll seek out the experts who do know and relay what I find to you. I'll also link you to those experts so you can get straight to the source yourself.
Stress, worry and anxiety don't have to be part of your daily life. I'll share everything I know so you can become your own expert. My goal is to equip and empower.
Now you have an anxiety expert in your pocket and together we will be Outsmarting Anxiety.
CBT stands for Cognitive-Behavioral Therapy. It is a type of talk therapy. In this type of therapy, a therapist helps the patient see how they may be thinking (cognitive) about things in a way that is not helpful and help them see things that they are doing (behavioral) that may be holding them back. The goal of the treatment is to (1) help the person understand their own patterns, (2) think more accurately about their situations, and then (3) plan actions that will help them reach their goals. In the course of the therapy, the therapist should help them practice their new “skills” in real-world situations.
For anxiety, CBT must include one important component – and that is what is called “exposure.” Exposure just means practice doing things that have been avoided, in small steps, in real-world situations, with the help and guidance of the therapist. If you are working with a CBT therapist for help with anxiety, this should be a major part of the treatment.
How long does CBT for anxiety take?
CBT for anxiety is short-term, which means it typically involves 8-14 sessions (2-4 months of weekly or every other week visits) and it is very goal-oriented - the goal being to reduce symptoms and improve functioning in the target areas. If there are multiple problems (like depression and anxiety) or the symptoms of anxiety are very severe and it has been going on for many years, it may take longer than 14 sessions, but you should be able to start seeing positive changes within the first couple of months.
In other words, you would not be sitting on the couch talking with your therapist about your week and problem solving day-to-day issues for the next few years. We call that “supportive counseling” which can be a very helpful and important form of support, but this would not be considered active CBT.
Here’s an example of CBT for Social Anxiety:
1. Cognitive work - they will uncover with their therapist the thoughts that frequently pop-up that intrude and cause anxiety, such as “I won’t know what to say,” “I’ll mess up and everyone will make fun of me.” Then together they will think of more helpful and accurate thoughts like “I’ll be nice to them and then if they are not interested, no big deal, I’ll find other things I enjoy doing and maybe someone else will want to play what I’m playing.” Or “Everyone messes up, and people aren’t really paying attention to what other people are saying,” “mean kids might laugh but they’re being mean to everyone and they’re doing it for attention – it’s not really about me.”
2. Behavioral Practice - They will uncover the things they may have been doing to avoid these types of feelings and situations, such as, sitting in the library during recess, or staying home from school on the day of the presentation. The therapist will explain that avoiding these situations actually makes the anxiety stronger, even though it feels better in the moment. They will plan practices (or exposures) that involve doing the things they have been avoiding in small steps. In the case of speaking in front of class, the child may practice reading out loud in front of the therapist, then reading a presentation off of note cards in front of the therapist, then doing the same presentation in front of a family member and the therapist, then at home in front of a few family members for “CBT homework,” then doing the same presentation while the therapist records on a camera, and if needed, they can do the presentation in front of the teacher during study hall for a practice. By the end of all of this practice NOT avoiding the presentation, the child will feel less anxious and more ready to do the presentation in front of class.
Important parts for Parents
In CBT for anxiety in kids, parents are very much part of the team. Parents are shown how to encourage practice and not give-in to avoidance or reassurance at home. In this example, if parents were asking the teacher for accommodation to write the report instead of read it in front of class, or let the child miss school on presentation day, the therapist would help them encourage practice of small steps (like have them practice in front of them a few times, then ask the teacher if they can practice 1:1 first before doing it in front of the class) instead of avoidance.
I get lots of urgent calls from parents right at the beginning of the school year, after long holidays, and even at the start of new sports seasons. They are asking for help because their child is having a “really hard time” going back to school or going to the first practice of the season. Starting something new is filled with uncertainty and this can bring on a lot of anxiety – which then can lead to a lot of avoidance.
1. Remind him/her that it’s uncomfortable, not dangerous: “It’s understandable you’re feeling this way at the start of something new. Your body thinks you’re in danger, and it’s important for you to remind it that a new year (or new team etc.) is uncomfortable, not dangerous.” If your child is stating a specific worry, say - OK what is one helpful or useful thought that you could think to challenge the worry? (you can add – “You’ve been to many first days and it always gets easier by the end - it's uncomfortable, but not something you can’t handle). Then ask "what is one action that can help get you to your goal" (you can add for example, that the goal is to learn something today - plan to focus on one skill to work on that you want to get better in).
2. Don't engage in a “debate” – keep your message short and simple: when you see an escalation or tears or upset, it’s easy to get sucked into a conversation to try to help them feel better. Instead of engaging in a debate about whether they should/should not go, or trying to convince them that it will be OK, just sit quietly and state calmly that it's important for you to go, so I’ll wait here until you’re ready to go. We will be going each day regardless, because it's important, it’s your responsibility, and I know you can do it. Don't say too much else – “being a broken record” saying this once every 10 minutes is better – debate/convincing always keeps the escalation going. Nothing else should happen until you “go” either – so no TV/read/play while you are waiting.
3. Try not to over-empathize with his/her discomfort: It is hard to see your child feel terrible. Be careful not to over-empathize – or feel what they are feeling too much - it will suck you into trying to make him more comfortable which will lead to the discussion of not going at all. The goal is to know they can tolerate being uncomfortable for a couple of hours.
4. Keep home time not so comfortable: Give structure/tasks/chores so there isn’t a stark contrast between demand/no demand when they have to leave home for things. That’s one of the problems with holidays – they are unstructured, lots of warm comfortable feelings, and it’s really hard to want to go back to a not warm and relaxing place like school. So I encourage you to keep the days at home a bit structured – waking up and going to sleep around the same time, keeping some school type of work (reading, math worksheets) as a responsibility most days, being expected to finish chores like cleaning room/making their bed/taking dog for walk, before other “fun” things can happen. Planning to meet up with school friends or playing in the school field also help, I always say to try to “blur the line” between home and school (or any other place they need to go) – this helps them to not feel uncomfortable at the thought of doing school type things when the time comes to go to school. In the summer holidays it’s good to start this plan at least 1-2 weeks before school starts.
5. Be confident that they will get there. Your belief about whether your child can/can not handle a difficult situation absolutely gets communicated in your interactions with them. When your child “reads” your belief, they will act from it (like when a child looks at your reaction and then starts crying when they see that you’re worried after a fall). Which is why it is so important for you to know and truly believe that the situation is something your child can handle. Knowing that it can be hard at first, but if you are consistent with your message and actions each day, they will get there. They will see that you believe that it’s important, and that they can do it. Then stay calm and steady in your plan to leave the house when it’s time, every time. Careful not to ask “do you think you’ll be able to go?” this communicates that you’re not sure they can handle it.
Just like if your child said he/she wasn’t sure they would ever be able to do multiplication. You wouldn't be worried inside or communicate that you were worried that maybe they wouldn't. You’d want to communicate your strong belief that it can be hard at first but that he/she’ll practice a little every day and eventually will get it. Similarly, you wouldn't give up and say OK you don't ever have to learn multiplication – you’d just find smaller steps, different ways to teach, and keep practicing. That’s the same with anxiety – you can find smaller steps (see our Child Anxiety Tales program for more about how you can do this), different ways to practice, but you must keep practicing – no such thing as “can’t,” just, “haven’t yet.” Know for sure they will get there.
Note: We understand that all children are different and use examples that are general and may not fit your child. We do not mean to minimize the struggle in learning math/multiplication for those kids who may have learning differences or learning disabilities. Please excuse the general nature of our examples.