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Eli Lebowitz, PhD - Guest
Eli Lebowitz, Ph.D. is the Director of the Program for Anxiety Disorders at the Yale Child Study Center, creator of SPACE (a parent-based treatment program for child and adolescent anxiety and related disorders), as well the author of Treating Childhood and Adolescent Anxiety: A Guide for Caregivers with Haim Omer and Breaking Free of Child Anxiety and OCD: A Scientifically Proven Program for Parents, his most recent published work. Dr. Lebowitz's research focuses on the development, neurobiology, and treatment of anxiety with a focus on cross-generational and family influences. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton, Psy.D: (00:22)
Welcome to Therapy On the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for The Advancement of Psychotherapy. Today, I'll be speaking with Eli Lebowitz Ph.D., who is a psychologist and director of the program for anxiety disorders at the Yale Child Study Center. He is the creator of supportive parenting for anxious childhood emotions or SPACE, a parent-based treatment program for child and adolescent anxiety. Additionally, Ellie is the co-author of Treating Childhood and Adolescent Anxiety, A Guide for Caregivers with him Omer, and the author of Breaking Free of Child Anxiety and OCD, a scientifically proven program for parents. Eli's research focuses on the development, neurobiology, and treatment of anxiety with a focus on cross-generational and family influences.
Dr. Keith Sutton, Psy.D: (1:18)
Let's listen to the interview. So hi, welcome Eli.
Dr. Eli Lebowitz, Ph.D.: (01:23)
It's great to be here. Thanks for having me.
Dr. Keith Sutton, Psy.D: (01:26)
Yeah, thanks for joining. So I learned about your work. Actually, through this podcast, I was interviewing Muniya Khanna about her work and she was referencing some of your research on the work you do with parents. Helping children with anxiety disorders just through the work with the parents. Then actually in another interview, I was doing with Lynn Lyons, you also came up. Then I got an email from a colleague saying “has anybody heard of this approach? This is really helpful for kids that are maybe a bit resistant to CBT”. So I thought, I gotta learn more about this, and actually, I bought your books. Particularly, your most recent book which is let me get the title here.
Dr. Keith Sutton, Psy.D: (02:09)
Which is the Breaking Free of Childhood Anxiety and O C D. I'm really interested to hear about your work, and your model. I actually, you know, do a lot of family work as well as CBT and integrate it. And there's an evidence-based, you know, approach for working with depression, with adolescents and families with depression. But really there's not much that I know of evidence-based working with anxiety. Most of the family work is kind of geared towards more acting out behaviors, oppositional behavior, substance abuse, and so on. So when I heard about this research I got really interested. So yeah, can you tell me a little bit about your work. I'd also, always love to hear people's stories about kind of the progression of their careers and how they got to this kind of point in their thinking and interests.
Dr. Eli Lebowitz, Ph.D.: (02:58)
Well, let's see, trying to think about where to start, because there are a couple of questions in there. I guess, you know, it's interesting what you said about so much of the work around evidence-based parent-based interventions being focused on the externalizing problem domain, and that's very true. Certainly in the externalizing problem domain, that's almost a default and there are hundreds of clinical trials of things like parent management, training, and other offshoots and related, you know, approaches a lot of overlap typically between them. And there has been so much less in the internalizing and certainly in the anxiety domain. And I mention it partly in agreement with what you said, but also because it does relate in one way to the question of, how did I come to this?
Dr. Eli Lebowitz, Ph.D.: (04:00)
The way that it relates actually goes back quite a few years now to an earlier time in my career many years ago now when I was working in a large children's hospital. I was actually working in two units at the same time, two programs, one of them was a program for childhood anxiety and there we did cognitive behavioral therapy. The other program was a parent counseling unit for youth with severe externalizing problems. So these were really, you know, families that were coping with very serious problems of aggression, violence, delinquent, and things like that. And there we worked with parents, as is common because youth with those problems are not always ideal candidates for their therapy themselves and are not always engaged in therapy themselves. Now, one of my jobs in the anxiety program was to screen incoming families and try to ascertain, you know, would this be an appropriate family for the program?
Dr. Eli Lebowitz, Ph.D.: (05:14)
Because we had more families than we could actually serve that were reaching out, we had a waitlist. And so I got in the habit of asking parents on the phone when they would first reach out to us in the anxiety program, does your child want help? And when they said no, then I would explain to them that we did cognitive behavioral therapy which was a therapy that's done with kids. It requires a high level of collaboration and motivation and if their kid wasn't interested in getting any kind of help, it was unlikely that we would be able to really be of tremendous use to them. But I just got increasingly frustrated because I would find myself sometimes on the very same day, having this conversation with the parents of a child, with anxiety and saying, well, if your child doesn't want help, there's not all that much we have to offer you.
Dr. Eli Lebowitz, Ph.D.: (06:08)
And then on the same day, I walk down the hall and I mean the parent counseling unit, and I'm telling parents, we don't need your kid to be here. We're gonna give you the tools. We're gonna empower you to make a difference. Even if they're not on board at all and this just led me to feel very frustrated. And I started to think more about what is there actually that we could be offering to parents of kids with anxiety and other related problems. And that was part of the impetus for the development of SPACE, which is really, a parent-based treatment for child anxiety and for child OCD. And it's not a treatment that is exclusively for parents of children who don't want help but if you are the parent of a child who doesn't want help. Then it's maybe the only treatment that is going to be really feasible to be implemented because it doesn't require the child's participation. And so that's, you know, a little bit of that. I'm happy to talk about it more, but maybe you have more specific questions.
Dr. Keith Sutton, Psy.D: (07:23)
Yeah, no, I think that's really interesting because I think that there are a lot of times that, and particularly parents get this idea too, is they call up and they say “but I don't know if they want to come”. I think they need to be ready or so on and actually one of my areas of specialty is oppositional defiance disorder. My colleague, Jim K is published a number of chapters and so on. We have an oppositional conduct disorder clinic as part of our practice. And so oftentimes letting parents know that like that's actually expected. That the kids don't want to because doing some of this work is going to change the power dynamics and you know, the kids are gonna lose power. Although of course, they want containment and so on, there's also, you know, handing over that power to parents is, is very anxiety-provoking.
Dr. Keith Sutton, Psy.D: (08:08)
But yeah. And then with children, with anxiety, you know, oftentimes both children and adults, sometimes the last thing they wanna do is do anything that's gonna lead to potentially more anxiety and avoidance is part of it. So like you're kind of saying it's inherent within the issue. Like, you know, and so definitely I'm looking forward to hearing how you kind of moved from there, because it sounds like a perfect matchup with your experience and looking like, “oh this is possible in this arena”. Let's bring it over to this arena.
Dr. Eli Lebowitz, Ph.D.: (08:37)
Yeah and you know, it's interesting. It's not that there have not been attempts to involve parents in the treatment of child anxiety. There have been attempts over the years. There's been, you know quite a few studies actually that have tried to. For example, to ask a question, can we augment child-based cognitive behavioral therapy by involving parents and you know, you look at those studies. We’re now talking about like three decades of research, 20 plus studies. You look at those studies and the answer is actually no, the answer has been fairly consistent. We have a meta-analysis of this. We have systematic reviews of this. The answer is actually no, involving the parents alongside doing the CBT with the kids actually haven't made a whole lot of difference and that is somewhat surprising. When you think about it, you think it would make a difference.
Dr. Eli Lebowitz, Ph.D.: (09:34)
I think that the real question we have to be asking is how do you involve the parents not whether you involve the parents. What does it mean to say there are many different things you might be doing when you look at those studies, “what have most of them done?” Well, what most of them have done is try to teach parents to do CBT on their kids. That's been the most common approach, we'll teach parents CBT, and then they will practice the CBT with the kids. It makes sense and it has some intuitive appeal. It does not seem to help and when I say it doesn't help, what I mean is it doesn't help relative to just doing the CBT with the child.
Dr. Eli Lebowitz, Ph.D.: (10:21)
I think though, and this is a lot of the, you know, the real premise of SPACE as a treatment rests on the idea that there's something we're missing in that model. It has to do with the fact that we have been conceptualizing and just thinking about child anxiety problems for so many years in basically exactly the same way that we think about adult anxiety problems. You know you take a manual for CBT, for adults with anxiety, and you take a manual for CBT, for children with anxiety and they're the same. The pictures are different and use shorter words when we're doing CBT with six-year-olds and we use longer words when we're doing it with 36 or 56-year-olds but they're basically the same. The thinking about these problems, the whole understanding of anxiety problems has basically been the same, right?
Dr. Eli Lebowitz, Ph.D.: (11:22)
It's that classic tripartite model of anxiety. The patient's thoughts, the patient's beliefs, the patient's behavior, and physical dysregulation. And how do you adjust those things? But one of the ideas that really inform SPACE as a treatment is that actual child anxiety problems are not the same as adult anxiety problems. They're meaningfully different. It's not that that model is wrong for kids. I don't believe it's wrong. I think it's right but I also think it's lacking. It's like partial, there's a whole piece that's just left out of it. So what is there, is right? But the problem is in, what's not there. What's not there is the fact that children actually respond to fear in a way that's different from adults. They respond to fear, not just with that, you know, individual kind of fight or flight response, the way an adult might.
Dr. Eli Lebowitz, Ph.D.: (12:25)
They respond to fear by looking to their caregivers, by looking to their parents, to step in and protect them and also regulate and soothe them. This starts at birth. It starts in infancy and really at birth, you know, think about a baby who's in distress. What are they going to do? There's really one thing they can do, they can cry. They can alert somebody else. You take a scared baby and that's what they do. They look away because that's the one thing they can control is their gaze. So they'll avert their gaze. But beyond that, they can't get up and run. They can't get up and fight. So what do they do? They cry. They socially signal somebody else. Right? They're sending off this signal. That's what we're programmed to do in childhood and that changes in adulthood, right?
Dr. Eli Lebowitz, Ph.D.: (13:15)
As we go through development, childhood adolescence, and into adulthood, that really changes significantly. So those adults who are scared, still have a little bit of social response, but their main response is really much more individual, right? It's like, how do I deal with this threat? Now, once you start thinking about child anxiety in this way, as an interpersonal system, right? Of signaling from a child and a parent, who is there to pick up those signals and respond to them and step in and protect this kid and reassure and soothe and regulate this kid. Once you start thinking about child anxiety at that interpersonal level, it really looks very different. And you start to see a role for parents that's way beyond teaching them to do what a therapist would do because they're not therapists, they're a parent. Right?
Dr. Eli Lebowitz, Ph.D.: (14:05)
The parents are almost inevitably getting drawn into these anxiety problems. Right? If you're anxious as a child, your parent is not just there as a therapist. They are the person you're looking to help you manage that fear. And so you're worried, you come to your parent with lots of questions about your work. You're scared to be alone. You're clinging to your parent and they start staying next to you, maybe sleeping next to you at night. You're socially anxious, they start speaking in place of you and managing your social interactions for you. All of these, are what we call accommodations. Right? All of these accommodations for child anxiety are almost inevitable in the context of a child's anxiety problem. That's what we focus on in SPACE. We focus on how parents respond to their child's anxiety, rather than on trying to take on the role of a therapist who's going to treat, so to speak, the child's anxiety.
Dr. Keith Sutton, Psy.D: (15:08)
Yeah. Yeah. And then, so.
Dr. Keith Sutton, Psy.D: (15:12)
You know, the way that I oftentimes think about it is that you know, parents are trying to help their kids and help them with their anxiety. Inadvertently they end up accommodating or reinforcing avoidance, which ends up becoming what the problem is. And that is not because the parent's trying to do anything bad or so on. It's more that they're trying to be caring and loving. But it sometimes gives a message that you know, anxiety or negative feelings are bad. We have to do something to get rid of them and talk and so on. So, therefore, you get the accommodating behaviors that end up kind of creating, like you're saying, the systemic effect, which I think is such an important piece because I think that really gets left off. I actually was thinking, as you were telling the story, of a story while you were talking about that. When I was with my daughter you know, in a jump bouncy house or salon when she was young and there was another little girl, probably three or four years old and a kid just bumped into her and knocked her flying and she fell down. She looked up at her mother and this like about to cry and her mom said, “ah, shake it off, shake it off.”
Dr. Keith Sutton, Psy.D: (16:16)
The girl goes, turns around, went boom, right back in again, and I was like struck by how that response. I think the girl also felt attuned to, but also, you know, she shifted in and realized, “okay, this isn't a horrible thing of what just happened. I can pick up and keep kind of moving forward” and so that was really a striking kinda thing just as a parent kinda scene.
Dr. Eli Lebowitz, Ph.D.: (16:37)
I think it's a great story and it's a story that every parent has experienced in one way or another, right? Like your toddler's learning to walk, they fall over, they look at you and there's that moment, you know, if you've had kids like, people know this moment. And there's like this silence and they're looking at you and if you look horrified, they're gonna start crying and it's gonna take a while to calm them down. And when you clap or smile and say “you're okay” then they giggle and they start walking again because they're looking at you and sort of understanding this situation. I think there's a really deep point. And when it comes to anxiety problems to children who have, you know, not just that normative, like sure, sometimes I'm going over or sometimes I'm gonna feel a little bit scared or a little bit anxious. But when you have a chronic anxiety problem and it's being persistently triggered, then all of those small responses, really add up to an incredibly powerful and impactful and important message.
Dr. Eli Lebowitz, Ph.D.: (17:38)
You know, sometimes the way I'll put it to parents is sometimes I'll say, “think of yourself as like a mirror that your child is looking into and they're seeing who they are. And if they're looking in that mirror and what they're seeing is I'm weak, I'm helpless, I'm vulnerable. I can't handle my anxiety. That is what they will believe.” And the worst, I don't wanna say the worst. I'll say the last message. The last message that you wanna give to a child who is vulnerable to anxiety is that they can't handle anxiety. That's such a discouraging and difficult and ultimately impairing kind of a message. I mean, we get this intuitively, we get this for other problems. We, you know, your kid was just, let's say your kid was just diagnosed with a physical problem like diabetes.
Dr. Eli Lebowitz, Ph.D.: (18:33)
You're never going to sit that kid down and say what a shame that you got diabetes because you can't handle it. What an awful message, right? Nobody would do that. You're gonna sit down and you're gonna say, you know, “it sucks, it's a challenge, It's difficult and you're gonna be fine and you're gonna be ok. We're gonna get through this, you’re strong. We'll adjust and we'll be okay.” If your child is vulnerable or predisposed to high levels of anxiety you might not be able to change that innate predisposition but you can definitely change how it's going to affect their lives. By giving them the message, they can handle this, Right? So much of the impairment in the world of anxiety, in all the anxiety disorders, is so much of the impairment comes from that determination, not to be anxious.
Dr. Eli Lebowitz, Ph.D.: (19:31)
That feeling of “I can't handle being anxious” and then you get trapped into this constant cycle of trying not to be anxious. You get more and more impaired and ultimately more and more anxious as well, which is just heartbreaking for all the effort that you're putting into it. The more you fight it, the worse it ends up getting. And so what we try to help parents to do in SPACE is really two things. You know, it's like, it's this whole evidence-based treatment clinical trials, but it's really about making two kinds of changes in how you're responding to your child's anxiety. And the great thing is that neither one of those requires you to force your child to do anything. You don't need at any point through all of SPACE, like whether you're doing it with a therapist or whether you're doing it on your own with the book that you mentioned, Breaking Free of Child Anxiety and OCD which is like a workbook, to work through this treatment on your own.
Dr. Eli Lebowitz, Ph.D.: (20:31)
Regardless of how you're doing it at no point, do you have to make your child do something or make them not do something because it's really all about your responses. So what are these two changes that we try to help parents to make? Well, one of them is to increase what we call their supportive responses to their anxious child, to become more supportive of your anxious child. And this is a very clear definition of exactly what I mean by supportive when we're in SPACE. Obviously, there are a lot of different ways to define the word support. Like lots of things could be thought of as supportive, but in SPACE. I really mean one a really clear recipe for what's a supportive message. It's like this, it's you're being supportive of your anxious child when you're showing them a combination of two things. When you're showing them acceptance, which means you're acknowledging what they experience. You're validating their genuine experience. You're not denying it or dismissing it or trying to tell them they don't feel it. Which sounds funny when I say it like that, but it's what we do so often, you know, kids say it's scary and parents say, no, it's not.
Dr. Keith Sutton, Psy.D: (21:53)
I remember you even in the book kind of differentiated, you know, some parents that are more accommodating in that taking over. Then, other parents are sometimes trying to help out, but more by dismissing, like it's fine, It's okay. They both kinda are on the extremes, you know, what's not helpful to kind of shifting anxiety.
Dr. Eli Lebowitz, Ph.D.: (22:16)
Yeah, exactly. You know, sometimes you fall into this more protective kind of a trap. Sometimes you fall into that more demanding style trap. Neither one is really supportive. You're being supportive when you're showing just simple acceptance. This is what you experience and it doesn't mean I have to feel exactly the same thing, but this is what you experience and I get that. And you combine that with confidence, with a message “I believe that you can handle feeling this way, that you can tolerate it, and you can get through it.” It can be as simple as saying to your child, something like, “I see that this is really difficult for you, or really scary for you, or uncomfortable for you, and I believe that you can handle that.” It's not about what they believe. It's not about what they're going to do, even if it's just, I'm telling you what I believe, but you're holding up that mirror that says, “I do see you and I do understand what you're going through, but I also believe that you can handle it.” Systematically increasing those supportive messages like really systematically, you know, writing them down and practicing saying them to your kid time and time again. That is the first of those two, like big picture changes that we try to do with parents in SPACE. The second is to reduce those accommodations and we don't do it all at once.
Dr. Eli Lebowitz, Ph.D.: (23:35)
You don't have to like, stop all your accommodations overnight, which would be difficult and overwhelming for the child too. And so we worked through it really systematically, you know, let's figure out how you are accommodating. Maybe you're not even realizing all the different ways that you're accommodating. Now we've done research on accommodation across the world from like every, I won't say every, but almost every part of the world, you know, Australia to Asia and, and America and Europe and middle east, et cetera. And everywhere that we've looked between like 97 and 100 percent of parents who have an anxious child report, very frequent accommodation.
Dr. Eli Lebowitz, Ph.D.: (24:20)
So we know this is almost a universal feature, but you're not always aware of it right away. Or maybe you're aware of a few, but there might be 10 others that you haven't even realized are accommodations. So you start just by noticing them, and then you choose one specific thing. And then you plan, how are you gonna make a change in that domain? And you let your child know about it in a really warm, loving, and supportive way and then you start systematically reducing those accommodations. It turns out that if parents can make those two changes, be more supportive and less accommodating to children, they can overcome even a serious, severe anxiety disorder within a fairly brief amount of time. And without even meeting directly with a therapist at all.
Dr. Keith Sutton, Psy.D: (25:09)
Wow. That's great. So I'm struck by what you're saying too, about the way that the parents are kind of reflecting. And it makes me think of Colley’s looking glass theory of self and the idea that we get our sense of self, of how we're reflected in other's kind of faces as they kinda are experiencing us. And it seems like, you know, this would be helpful with kids, with anxiety, as well as even, you know, kids that are acting out. Particularly with the, you know, I do a lot of work with kids with ADHD, and oftentimes, they mess up 10 times more. They're more frustrating and sometimes there's a whole overlap with oppositional defiance because oftentimes everybody's getting so frustrated. And so they kind of get the sense that I'm a frustrating kid and then sometimes kind of respond to that in a reactive way.
Dr. Keith Sutton, Psy.D: (25:55)
But I think that those aspects, even of just like you're saying the acceptance and the confidence. Like accepting mistakes and confidence that they can, you know, they're still a good kid they can figure out or so on. I think it sounds like it actually would probably work both in externalizing as well as this kind of internalizing, you know, situation. That's great, and particularly I would love to hear about any examples or so on. I mean, I was just thinking about, you know, reducing the accommodations and say, you know, you've got a kid who's, you know, having trouble sleeping through the night. They're sleeping in the parents' room or want the parents to sleep in their room. And particularly I know for a lot of parents that oftentimes they feel mean when they're not providing that accommodation anymore and they have a hard time kind of. And particularly oftentimes there's a large reaction from the kids because they were getting that response before and now they're not. And oftentimes that will escalate their distress. Tell me a little bit about that and how you kind of work with that, with parents.
Dr. Eli Lebowitz, Ph.D.: (26:59)
Yeah, absolutely. It comes as a shock to absolutely nobody that when parents do start reducing their accommodations, children do not universally thank them. Right? They don't always embrace them and congratulate them on understanding child anxiety on such a deep level. They don't always do that. Sometimes they do that or some approximation of that, but they don't always do that. Sometimes they get frustrated, they get anxious, and they get upset. They might say things that are really hard for a parent to hear like, “you don't care about me, you don't love me, or this is bad for me.” Or they might try to persuade, or they may simply nag and pester them to a point that the parent feels like they're witts end. And because this comes as a shock to no one we're quite well prepared for that. And, you know, we sort of take it for granted, but this is not always going to be an easy process.
Dr. Eli Lebowitz, Ph.D.: (28:08)
Sure and parents need to be aware of that too. The thing, the one thing that probably more than anything else makes it manageable and easier is actually the thing that I mentioned before, which is that you're not here trying to make your child do something. Why is that so important? Because when you are trying to get your child to do something, you have no escape from the situation until you've won, so to speak. It's a power struggle. It's a zero-sum game, right? Like either you're gonna give up, surrender, and give in and you feel like a loser, failure, and worried about never getting anything done and et cetera. Or you're going to push and push and push until you overcome your child's existence at the cost of a lot of conflicts and often a lot of escalation, and that traps you into the argument, right?
Dr. Eli Lebowitz, Ph.D.: (29:09)
It's like, you come to your kid “do your homework.” “I don't wanna do my homework.” “But you have to do your homework.” “But why should I do my homework?” You have no escape from this, right. Until you get them to do their homework. In SPACE, we make it a really clear point not to get into that struggle in the first place. Because when my plan, as it always is in SPACE, is only about my behavior, I can simply do it and walk away. I don't need to stay trapped. Now you may wanna continue arguing with me but there's no real need for me to argue back because I'm not asking anything of you. And so when you are calling to come to sleep next to me, as you did in the past, it's still hard for me. It's still really hard.
Dr. Eli Lebowitz, Ph.D.: (30:30)
And I need to remind myself that what I'm doing now is the opposite of cruel, it's a gift. In fact, there is no bigger gift that you can give an anxious child than the belief that they can cope with anxiety. It's the best thing you can do about that. And sometimes that's hard just like, you know, holding your baby when they need to get a shot. And it hurts, it’s hard, but it's also a gift, right? You're keeping them safe. You're keeping them healthy. And you're keeping your anxious child strong and healthier by instilling in them that confidence that they can handle their difficulty. So it's still hard, but it's a lot more doable when I know that at least I don't need to force anything on you. I'll give you an example from like sure, take a child with, I don't know.
Dr. Eli Lebowitz, Ph.D.: (30:53)
Let's take a child with social anxiety who doesn't, you know, has a lot of difficulty speaking for themselves and they rely on other people to speak for them. So they go to class and they whisper to the kid next to them to say something to the teacher or they just sit there and never raise their hand. Or they go to the library, and the parent asks the librarian for the book that they want because they're like, “I don't wanna talk.” We go to the restaurant, the parent may put in the order for them. Right? Lots of parents will have encountered this and lots of therapists will have encountered this. Some people like me will have encountered it both as a parent and as a therapist, that's pretty common too. And so we wanna try to work on this accommodation, right?
Dr. Eli Lebowitz, Ph.D.: (31:37)
So I've been accommodating to the parent, you've been accommodating by speaking to that waiter for your child. Now, if we were to make a plan that says, starting tomorrow, we're gonna go to restaurants and you're gonna order for yourself. We would have a problem because what would happen is we would go to the restaurant and then we would say, “okay, remember the plan is you are ordering for yourself.” And the kid would say, “no, no, no, that's your plan. That was never my plan. That was just your plan and I don't wanna order for myself.” And then you'd start persuading them “come on, you can do it. Come on now.” First, you're a cheerleader and then you get angry. You go through that cycle. Now you're annoyed. And you end up storming out of the restaurant, then whatever. Until you try again in SPACE, we would never make that plan in the first place.
Dr. Eli Lebowitz, Ph.D.: (32:25)
What would we say? We would say, “I'm simply not gonna order it for you. And I'm gonna let you know that in advance. I'm not gonna like surprise you with it.” I'm gonna tell you, “I know it's hard for you when have to speak for yourself or when someone speaks to you, I get that. That makes you uncomfortable and I believe that you can handle that.” That's that supportive message. I don't think I'm helping you by always speaking for you. And so from now on, when we go to a restaurant, I'm not going to put in the order for you. I'm not saying what you're gonna do. We go to the restaurant the next time I just need to remind myself not to do it. And maybe you end up ordering for yourself. Maybe you don't, but there's no pressure on you. Maybe you do it the second time that we practice this, or the third time that we practice this. And you know what, even if you didn't order for yourself, we can go home. And I can say, “I'm proud of you for getting through it without my ordering for you. Even if you never order it for yourself, you know what? You handled my plan and I'm proud of that.” When you do it that way it actually becomes a lot more likely that pretty soon the child will give it a try.
Dr. Keith Sutton, Psy.D: (33:35)
Sure.
Dr. Eli Lebowitz, Ph.D.: (33:36)
Right, and this is the important thing. Like, even though we're never trying to directly tell the child what to do at the end. When we do clinical trials of SPACE, what we're looking at in the outcome is actually changed in the child. We want to know, is this child getting better?
Dr. Keith Sutton, Psy.D: (33:50)
Yeah.
Dr. Eli Lebowitz, Ph.D.: (33:51)
And that's what we're seeing.
Dr. Keith Sutton, Psy.D: (33:53)
Righ, so that's, it really strikes me. I mean, particularly thinking about the work we do with kids where there's opposition. Oftentimes we're focusing, on helping parents shift from an outcome orientation to a process orientation. Because I think like you're saying, if they're focusing on the outcome of giving the order, they don't have much power over that. And particularly with kids, they'll let you know how much power you really don't have when you get into those kinds of power struggles. And so that idea of kind of the parent just focusing on what they're gonna do or not do, I think is so significant because that's really where they have to control. Also, I think I like the way you frame it, you know, it's up to the kids. It's their choice, whether they wanna order or not, and really kind of putting it into their hands.
Dr. Keith Sutton, Psy.D: (34:39)
How does this, you know, tell me about the overlay with also parental anxiety and the research. I oftentimes kind of reference sometimes in relation to the systemic work and anxiety. I think it was a Barrett et. all, they did some research using the coping koala and they just worked with the anxious kids alone. They compared that to the anxious kids where they also treated the parents. If the parents had an anxiety disorder and there was no difference in the outcome, but at follow-up, there was a much more significant relapse in the kids with the parents who had anxiety but did not receive some treatment. So I was just kind of thinking, even in this case example of someone, you know, at the restaurant, a parent coming back and saying, “but if they don't eat, that's really bad.”
Dr. Keith Sutton, Psy.D: (35:31)
Like what if they don't, you know, and sometimes the anxiety that comes up for the parent around that. I think there's both anxieties about like, you know, what if they don't eat or so on and for a lot of parents too, you know, there's a lot of anxiety around the feelings and listening. Sometimes the kids go to a negative place, particularly with my adolescence. I'm working with a family and one of the kids, he is worried that if he doesn't do good in the class, he's not gonna get into the right high school. He is not gonna get into college and everything's going to be lost. And he goes to this kind of dark place and the parents are trying to cheerlead and say, “but what about this? Or what about that or so on.” And, part of it is also as we're working, is helping the parents sit with their own distress and kinda being with their kids and their anxiety. So, lots on kinda that aspect, like the, you know, example of like the kid won't, you know, but then he won't eat and the anxiety that the parent might experience around that.
Dr. Eli Lebowitz, Ph.D.: (36:29)
You know, first of all, just acknowledging what you said about the research. You're making what is actually an important point because I sort of with a very kinda rough summary said “okay, we have decades of research treating the parent alongside treating the child. Hasn't really improved outcomes and the big picture that is correct.” It is true that there is data to suggest that when parents themselves are severely anxious treating the parents' anxiety alongside treating the child's anxiety does have some beneficial outcomes. It's just that's a small enough part of the overall population of anxious kids that when you look at the overall numbers, you don't see a strong effect.
Dr. Keith Sutton, Psy.D: (37:14)
Well, it sounds like you're saying too that when you're just teaching the parents, the techniques, rather than actually treating the parents' anxiety it probably has a big difference. Because that might be anxiously trying to get the kid to like, you know, that's irrational thought or something, rather than again, doing some of the acceptance or whatever it might be.
Dr. Eli Lebowitz, Ph.D.: (37:32)
Yeah, but to the main point I think of what you were raising, first of all, and I say this kinda jokingly, but if we were to develop a treatment for child anxiety that only worked for children whose parents are not anxious. Then we would have a somewhat limited product or tool because we know a lot of children will have anxious parents and a lot of anxious children will have anxious parents. I say that as a correlational statement, not as a causal statement. We actually don't know a whole lot about the causal pathways, linking child anxiety, and parent anxiety. But we know that even just at a baseline level, anxiety is so common that lots of kids are going to have anxious parents, even if they're not anxious themselves.
Dr. Keith Sutton, Psy.D: (38:24)
Right.
Dr. Eli Lebowitz, Ph.D.: (38:25)
And that correlation is there. I'm always really careful about anything that sounds like it's, you know, getting a little bit too causal sounding because as somebody that works in the field of parent-based treatment. I'm very keenly aware of the risk of being understood to be suggesting that parents cause children's anxiety problems in the first place.
Dr. Keith Sutton, Psy.D: (38:52)
There's a long history of blaming, you know? And so I'm glad you're pointing that out because that is so important.
Dr. Eli Lebowitz, Ph.D.: (39:00)
Yes. There's such a long and frankly, shameful history of blaming parents for everything, like autism and everything in between. It is not only real and hurtful, but it's also just wrong. It's just false, time and again, empirical data doesn't actually support these theories. Right, and so I like to be really clear that I don't work with parents because I think that they are the cause of their children having anxiety problems. In fact, I believe that's not the case for the vast majority of cases known, putting aside really horrible parenting like abusive, neglectful, and maltreatment. Of course, that's going to have a detrimental impact, but that's not the story for most kids who have an anxiety problem. That's not the story for almost all of them
Dr. Keith Sutton, Psy.D: (39:51)
Many families that I work in with too, if there's a sibling, oftentimes they might have a sibling that's doing well. So I can say, “see, the average parenting is doing well in this situation. It's that this kid needs something different.” And that it's not because you did something wrong, but it's more than that. Again, almost like the kid with diabetes, there's something extra that you might not, you know, be aware of.
Dr. Eli Lebowitz, Ph.D.: (40:25)
Right, and you don't have to give your kid anxiety to wanna help them if they have it either. Right. That's the question of like, “I care about this kid. I love them. If I can help them, why would I not want to? why do I have to be the perpetrator of something bad in order to help my kid?” It makes no sense when you think about it. So I'm just like taking the opportunity to make that really emphatically explicit because it's an important point. But, I mean a lot of parents are going to be more anxious themselves. Sometimes that means that they're gonna go a little bit slower in the process and that's okay. You know, you need to make a plan that's going to work for you. Whether you're doing it alone or doing it with a therapist, you need to make a plan that's gonna work for you.
Dr. Eli Lebowitz, Ph.D.: (41:07)
You also need to sort of build up your own confidence in your child and that's one of the things that happens in SPACE. It starts happening even before you start reducing accommodation, just from making those supportive statements. You know you hear yourself saying to your child a few times a day for a couple of weeks, “I believe you can handle it.” And you may start to feel like actually they can handle it. And then you start working on that accommodation and you remember that. Yeah, it's hard. I'm asking them to do something hard and I have to do something hard too. I'm telling my child, “I believe you can get through this difficult moment”, but I need to get through a difficult moment too. I need them to tolerate and regulate and cope and I need to tolerate, regulate, and cope, and that's okay.
Dr. Eli Lebowitz, Ph.D.: (42:00)
As a therapist, when we're doing SPACE we need to support the parents, just like the parent needs to support the child. Right, and there's a little bit of a parallel process there because this is a hard thing but it's easier to tolerate the stress and suffering when there's a meaning to it. When there's a purpose, you know, to just suffer is bad. You don't need to be Victor Franklin from the book of therapy to realize that when you view your difficult moment with some meaning when it has a purpose, it's a step toward overcoming a really big challenge. When this difficulty that my child and I are experiencing right now is building a foundation for them to live a happier, better life. It's a lot more tolerant and so if you know that you as a parent just cannot accept the idea that your child won't eat at the restaurant then maybe that's not the accommodation to start with and pick a different one.
Dr. Eli Lebowitz, Ph.D.: (43:08)
If it's uncomfortable for you, but you can see it as a step forward and they will go home and eat something then maybe give them a chance because you may be surprised by your child. You know when parents think, “oh, I could never do that to my child.” They're forgetting that there's actually the possibility that it won't even go the way they think. You're sort of assuming that, “okay, so we're gonna have to leave my child's gonna sit there a whole meal and won't eat anything.” But when you actually do back away a little bit and you give them the support and the opportunity, they may actually show you that they can do a lot more than you thought. And one of the things that I hear the most, and that I love hearing the most, from parents who are doing SPACE, or have recently done it, is how we realized as parents that our child is capable of so much more than we thought.
Dr. Eli Lebowitz, Ph.D.: (43:58)
Because when you're always stepping in preemptively or at the first signal of distress to rescue them, you actually don't realize that they can do a lot more than you realize. And I think that that's so important from the child's perspective of themselves as well. You know, there's something great about always being rescued, knowing that there's always someone there who's gonna like come and rescue you. But there's also something really vulnerable about always needing to be rescued. Right, like it's a place of a lot of vulnerability, so it's great that you're there to do it, but wouldn't it be great if I didn't need to be rescued all the time.
Dr. Keith Sutton, Psy.D: (44:36)
Yeah.
Dr. Eli Lebowitz, Ph.D.: (44:38)
Right. Or, to use another metaphor, you know, if your child can only eat when you feed them, then it's great that you are always there to feed them. Right, but it also really limits them.
Dr. Keith Sutton, Psy.D: (44:54)
Yeah.
Dr. Eli Lebowitz, Ph.D.: (44:55)
Because how do I grow to be independent? How do I go anywhere else? How do I feel like I can be okay on my own if I always need somebody there to rescue me or to feed me? Wouldn't it be great if I could actually just handle that for myself, and then I wouldn't need that service? And so I think parents often realize, anxious parents and non-anxious parents, and will come to this realization that actually my child is capable of a lot more than maybe I would've credited.
Dr. Keith Sutton, Psy.D: (45:21)
Yeah. I oftentimes think that that's the greatest gift. Sometimes a parent can give a child that kind of faith or that confidence in them that they're going to figure it out. So even if they're kind of, something's not going so well, you know, the parents, of course, depending on the age of the child involved and kind of steering things. But having that kind of mentality of like, I know you're gonna figure this out, or I know you're gonna get through this will get you on whatever path you need to be getting on there. And that can really help build that kinda perspective of resilience for the kids to really kind of overcome difficulties and take risks and challenges really grow.
Dr. Keith Sutton, Psy.D: (46:06)
I really love this program. I really like too, you know, like you're saying that it's really not focused on getting into a power struggle of the kid of getting them not to do something. But more kind of the parent shifting on their own kind of decisions in their own kind of what they're gonna do or not do, you know, and really kind of shifting away. Oftentimes that will have an effect on the outcome, but not being so attached to the outcome because sometimes then it will be disingenuine. And to that aspect that you're talking about of the parent being willing makes me think of an acceptance commitment therapy. The idea of, you know, being willing to go toward, go through distress or sitting with uncomfortable feelings to go in the direction of one's values.
Dr. Keith Sutton, Psy.D: (46:55)
So that connection to the values or the meaning allows the person to kind of sit with that distress to kind of move in that direction. Which might be sitting there while their kid's not eating or, you know, sitting there while their kid's kind of going to that negative place or whatever it might be and that's hard. It's the muscle built, you know, and I think like you're saying that parallel process of also being accepting and understanding that it's hard. While at the same time also having the confidence that the parent can do it and kinda build that.
Dr. Eli Lebowitz, Ph.D.: (47:30)
Yeah. You said it perfectly.
Dr. Keith Sutton, Psy.D: (47:34)
Great. Well, this is wonderful, and anything that you're working on now? When did you put out the book for the parents? I recently got it and it's great. I'm just getting up to the accommodation part now.
Dr. Eli Lebowitz, Ph.D.: (47:48)
That's awesome. Let me know when you're through and what you thought. It came out in January, so that's pretty new.
Dr. Eli Lebowitz, Ph.D.: (47:58)
Yeah, we're recording this in April. So it came out and was sold out on the first day that it came out. It is back in stock so people can find it and get it as an audiobook and as an ebook. They make it really easy to find, you know, in terms of things we're working on now. There are a couple of things that maybe are of interest. You know, one thing is that we're continuing to build the evidence base for the first base. So we've completed multiple randomized control trials. We're doing a randomized control trial right now where we're also using brain imaging both before and after treatment using functional magnetic resonance imaging, or fMRI. Actually, to learn more about what is changing in a child's brain, as these changes are happening at the family level and their anxiety is improving.
Dr. Eli Lebowitz, Ph.D.: (49:02)
And I think that's really fascinating and we'll be sharing some of those results in, you know, research articles in the near future. Another area that we've been working on is actually some expansions of SPACE to additional areas that lend themselves to this kind of approach. You mentioned some of the attention problems. For example, there are a couple of areas that we have been already working in such as what DSM calls ARFI or avoidant restrictive food intake disorder. Normal people call it very picky.
Dr. Keith Sutton, Psy.D: (49:44)
Sure.
Dr. Eli Lebowitz, Ph.D.: (49:45)
And, you know, ARFI was a natural for us for a couple of reasons. One is we were kind of already seeing that except we were labeling it food phobia, or some anxiety label, but actually we realized we were treating ARFI. And once we realized that, you know, it really became apparent that this was another area that lent itself to this kind of approach because it is heavily accommodated. You know, parents are so motivated for their child to just eat.
Dr. Keith Sutton, Psy.D: (50:18)
Yeah. Right.
Dr. Eli Lebowitz, Ph.D.: (50:19)
There are a few things that, you know, every parent wants for their kid, but certainly one of them is that they'll eat. If my child doesn't eat, you'll go to great lengths and this can trap you into another cycle of accommodation and also of impairment. The impairment really comes from this limitation that, you know, maybe my parents will accommodate me like this, but nobody else would. Right, and so how can I go anywhere else to eat? And we as a family, can we go anywhere? Can I go to play dates and sleepovers? And so you get a lot of impairment. In a development that was spearheaded by a former postdoc and now a colleague of mine, truly took the SPACE model and applied it to ARFI. With some small adaptations and some additions because there are some unique characteristics to ARFI that are different but there's also enough that's shared, we've published the clinical trial data on that. I think that's exciting. We have an adaptation of SPACE that we're currently doing a clinical trial for working with parents of adult children.
Dr. Keith Sutton, Psy.D: (51:34)
Oh Great.
Dr. Eli Lebowitz, Ph.D.: (51:35)
And, in particular, adult children who are not transitioning to independent functional adults.
Dr. Keith Sutton, Psy.D: (51:43)
Struggling with launching
Dr. Eli Lebowitz, Ph.D.: (51:45)
Yeah, exactly. People often call it failure to launch.
Dr. Keith Sutton, Psy.D: (51:50)
I mean, this is perfect for that cause. Oftentimes I'm helping parents in those situations to say like, you know, can't make you do anything, but I can't necessarily support you in these ways. So I'm gonna kind of step away from giving money or doing whatever it is that's kinda potentially, you know, enabling. I don't really like that word enabling, but it's those accommodations and trying to help out. But sometimes scaling back, not as to be mean, but just to say, “this is the way that I can feel okay about not contributing to this problem.”
Dr. Eli Lebowitz, Ph.D.: (52:21)
Exactly, I mean if I, as a parent, am so concerned about my adult child's function and you know, people talk about young adults. I don't say, young adults. I just say adults because I worked with parents of people who are absolutely not young adults. They're just adults and you know, this doesn't have like a natural endpoint. There's no expectation for it.
Dr. Keith Sutton, Psy.D: (52:42)
Yeah.
Dr. Eli Lebowitz, Ph.D.: (52:43)
And so if I'm so concerned, you know, I need to find a way to not be providing for you the optimal environment in which to not function. Like it just doesn't make sense that I would be doing that, but it's really hard for parents to make any kind of change. And so we have a version, you know, of SPACE for working with those parents and, you know, kind of gradually extending into other areas.
Dr. Keith Sutton, Psy.D: (53:15)
Perfect. Well, this is wonderful. Thank you so much for taking the time. It's great to hear about the model and it seems like such a caring model. Also, you know, really kind of that aspect of the providing that parallel process of the support and confidence for the parents and helping them provide that for the kids. And again, in a way that is really kind of self-directed and not, you know, pushing up against power struggles. It sounds like that's some great kind of things in the future as you're kinda expanding it to different areas. So I appreciate you taking the time today, and telling us more about the model and it sounds great.
Dr. Eli Lebowitz, Ph.D.: (53:57)
Well, thank you so much for having me on.
Dr. Keith Sutton, Psy.D: (53:58)
It's been a pleasure. Thanks a lot. Take care. Thank you for joining us. If you're wanting to use this podcast or continuing education credits, please go to our website at therapyonthecuttingedge.com. Our podcast is brought to you by the Institute for The Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco bay area. IAP provides training for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. For more information, go to SFIAP.com or call 415-617-5932. Also, we really appreciate the feedback. If you have something you're interested in, something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us. We're always looking for advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to Therapy On the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the director of the Institute for The Advancement of Psychotherapy. Today, I'll be speaking with Eli Lebowitz Ph.D., who is a psychologist and director of the program for anxiety disorders at the Yale Child Study Center. He is the creator of supportive parenting for anxious childhood emotions or SPACE, a parent-based treatment program for child and adolescent anxiety. Additionally, Ellie is the co-author of Treating Childhood and Adolescent Anxiety, A Guide for Caregivers with him Omer, and the author of Breaking Free of Child Anxiety and OCD, a scientifically proven program for parents. Eli's research focuses on the development, neurobiology, and treatment of anxiety with a focus on cross-generational and family influences.
Dr. Keith Sutton, Psy.D: (1:18)
Let's listen to the interview. So hi, welcome Eli.
Dr. Eli Lebowitz, Ph.D.: (01:23)
It's great to be here. Thanks for having me.
Dr. Keith Sutton, Psy.D: (01:26)
Yeah, thanks for joining. So I learned about your work. Actually, through this podcast, I was interviewing Muniya Khanna about her work and she was referencing some of your research on the work you do with parents. Helping children with anxiety disorders just through the work with the parents. Then actually in another interview, I was doing with Lynn Lyons, you also came up. Then I got an email from a colleague saying “has anybody heard of this approach? This is really helpful for kids that are maybe a bit resistant to CBT”. So I thought, I gotta learn more about this, and actually, I bought your books. Particularly, your most recent book which is let me get the title here.
Dr. Keith Sutton, Psy.D: (02:09)
Which is the Breaking Free of Childhood Anxiety and O C D. I'm really interested to hear about your work, and your model. I actually, you know, do a lot of family work as well as CBT and integrate it. And there's an evidence-based, you know, approach for working with depression, with adolescents and families with depression. But really there's not much that I know of evidence-based working with anxiety. Most of the family work is kind of geared towards more acting out behaviors, oppositional behavior, substance abuse, and so on. So when I heard about this research I got really interested. So yeah, can you tell me a little bit about your work. I'd also, always love to hear people's stories about kind of the progression of their careers and how they got to this kind of point in their thinking and interests.
Dr. Eli Lebowitz, Ph.D.: (02:58)
Well, let's see, trying to think about where to start, because there are a couple of questions in there. I guess, you know, it's interesting what you said about so much of the work around evidence-based parent-based interventions being focused on the externalizing problem domain, and that's very true. Certainly in the externalizing problem domain, that's almost a default and there are hundreds of clinical trials of things like parent management, training, and other offshoots and related, you know, approaches a lot of overlap typically between them. And there has been so much less in the internalizing and certainly in the anxiety domain. And I mention it partly in agreement with what you said, but also because it does relate in one way to the question of, how did I come to this?
Dr. Eli Lebowitz, Ph.D.: (04:00)
The way that it relates actually goes back quite a few years now to an earlier time in my career many years ago now when I was working in a large children's hospital. I was actually working in two units at the same time, two programs, one of them was a program for childhood anxiety and there we did cognitive behavioral therapy. The other program was a parent counseling unit for youth with severe externalizing problems. So these were really, you know, families that were coping with very serious problems of aggression, violence, delinquent, and things like that. And there we worked with parents, as is common because youth with those problems are not always ideal candidates for their therapy themselves and are not always engaged in therapy themselves. Now, one of my jobs in the anxiety program was to screen incoming families and try to ascertain, you know, would this be an appropriate family for the program?
Dr. Eli Lebowitz, Ph.D.: (05:14)
Because we had more families than we could actually serve that were reaching out, we had a waitlist. And so I got in the habit of asking parents on the phone when they would first reach out to us in the anxiety program, does your child want help? And when they said no, then I would explain to them that we did cognitive behavioral therapy which was a therapy that's done with kids. It requires a high level of collaboration and motivation and if their kid wasn't interested in getting any kind of help, it was unlikely that we would be able to really be of tremendous use to them. But I just got increasingly frustrated because I would find myself sometimes on the very same day, having this conversation with the parents of a child, with anxiety and saying, well, if your child doesn't want help, there's not all that much we have to offer you.
Dr. Eli Lebowitz, Ph.D.: (06:08)
And then on the same day, I walk down the hall and I mean the parent counseling unit, and I'm telling parents, we don't need your kid to be here. We're gonna give you the tools. We're gonna empower you to make a difference. Even if they're not on board at all and this just led me to feel very frustrated. And I started to think more about what is there actually that we could be offering to parents of kids with anxiety and other related problems. And that was part of the impetus for the development of SPACE, which is really, a parent-based treatment for child anxiety and for child OCD. And it's not a treatment that is exclusively for parents of children who don't want help but if you are the parent of a child who doesn't want help. Then it's maybe the only treatment that is going to be really feasible to be implemented because it doesn't require the child's participation. And so that's, you know, a little bit of that. I'm happy to talk about it more, but maybe you have more specific questions.
Dr. Keith Sutton, Psy.D: (07:23)
Yeah, no, I think that's really interesting because I think that there are a lot of times that, and particularly parents get this idea too, is they call up and they say “but I don't know if they want to come”. I think they need to be ready or so on and actually one of my areas of specialty is oppositional defiance disorder. My colleague, Jim K is published a number of chapters and so on. We have an oppositional conduct disorder clinic as part of our practice. And so oftentimes letting parents know that like that's actually expected. That the kids don't want to because doing some of this work is going to change the power dynamics and you know, the kids are gonna lose power. Although of course, they want containment and so on, there's also, you know, handing over that power to parents is, is very anxiety-provoking.
Dr. Keith Sutton, Psy.D: (08:08)
But yeah. And then with children, with anxiety, you know, oftentimes both children and adults, sometimes the last thing they wanna do is do anything that's gonna lead to potentially more anxiety and avoidance is part of it. So like you're kind of saying it's inherent within the issue. Like, you know, and so definitely I'm looking forward to hearing how you kind of moved from there, because it sounds like a perfect matchup with your experience and looking like, “oh this is possible in this arena”. Let's bring it over to this arena.
Dr. Eli Lebowitz, Ph.D.: (08:37)
Yeah and you know, it's interesting. It's not that there have not been attempts to involve parents in the treatment of child anxiety. There have been attempts over the years. There's been, you know quite a few studies actually that have tried to. For example, to ask a question, can we augment child-based cognitive behavioral therapy by involving parents and you know, you look at those studies. We’re now talking about like three decades of research, 20 plus studies. You look at those studies and the answer is actually no, the answer has been fairly consistent. We have a meta-analysis of this. We have systematic reviews of this. The answer is actually no, involving the parents alongside doing the CBT with the kids actually haven't made a whole lot of difference and that is somewhat surprising. When you think about it, you think it would make a difference.
Dr. Eli Lebowitz, Ph.D.: (09:34)
I think that the real question we have to be asking is how do you involve the parents not whether you involve the parents. What does it mean to say there are many different things you might be doing when you look at those studies, “what have most of them done?” Well, what most of them have done is try to teach parents to do CBT on their kids. That's been the most common approach, we'll teach parents CBT, and then they will practice the CBT with the kids. It makes sense and it has some intuitive appeal. It does not seem to help and when I say it doesn't help, what I mean is it doesn't help relative to just doing the CBT with the child.
Dr. Eli Lebowitz, Ph.D.: (10:21)
I think though, and this is a lot of the, you know, the real premise of SPACE as a treatment rests on the idea that there's something we're missing in that model. It has to do with the fact that we have been conceptualizing and just thinking about child anxiety problems for so many years in basically exactly the same way that we think about adult anxiety problems. You know you take a manual for CBT, for adults with anxiety, and you take a manual for CBT, for children with anxiety and they're the same. The pictures are different and use shorter words when we're doing CBT with six-year-olds and we use longer words when we're doing it with 36 or 56-year-olds but they're basically the same. The thinking about these problems, the whole understanding of anxiety problems has basically been the same, right?
Dr. Eli Lebowitz, Ph.D.: (11:22)
It's that classic tripartite model of anxiety. The patient's thoughts, the patient's beliefs, the patient's behavior, and physical dysregulation. And how do you adjust those things? But one of the ideas that really inform SPACE as a treatment is that actual child anxiety problems are not the same as adult anxiety problems. They're meaningfully different. It's not that that model is wrong for kids. I don't believe it's wrong. I think it's right but I also think it's lacking. It's like partial, there's a whole piece that's just left out of it. So what is there, is right? But the problem is in, what's not there. What's not there is the fact that children actually respond to fear in a way that's different from adults. They respond to fear, not just with that, you know, individual kind of fight or flight response, the way an adult might.
Dr. Eli Lebowitz, Ph.D.: (12:25)
They respond to fear by looking to their caregivers, by looking to their parents, to step in and protect them and also regulate and soothe them. This starts at birth. It starts in infancy and really at birth, you know, think about a baby who's in distress. What are they going to do? There's really one thing they can do, they can cry. They can alert somebody else. You take a scared baby and that's what they do. They look away because that's the one thing they can control is their gaze. So they'll avert their gaze. But beyond that, they can't get up and run. They can't get up and fight. So what do they do? They cry. They socially signal somebody else. Right? They're sending off this signal. That's what we're programmed to do in childhood and that changes in adulthood, right?
Dr. Eli Lebowitz, Ph.D.: (13:15)
As we go through development, childhood adolescence, and into adulthood, that really changes significantly. So those adults who are scared, still have a little bit of social response, but their main response is really much more individual, right? It's like, how do I deal with this threat? Now, once you start thinking about child anxiety in this way, as an interpersonal system, right? Of signaling from a child and a parent, who is there to pick up those signals and respond to them and step in and protect this kid and reassure and soothe and regulate this kid. Once you start thinking about child anxiety at that interpersonal level, it really looks very different. And you start to see a role for parents that's way beyond teaching them to do what a therapist would do because they're not therapists, they're a parent. Right?
Dr. Eli Lebowitz, Ph.D.: (14:05)
The parents are almost inevitably getting drawn into these anxiety problems. Right? If you're anxious as a child, your parent is not just there as a therapist. They are the person you're looking to help you manage that fear. And so you're worried, you come to your parent with lots of questions about your work. You're scared to be alone. You're clinging to your parent and they start staying next to you, maybe sleeping next to you at night. You're socially anxious, they start speaking in place of you and managing your social interactions for you. All of these, are what we call accommodations. Right? All of these accommodations for child anxiety are almost inevitable in the context of a child's anxiety problem. That's what we focus on in SPACE. We focus on how parents respond to their child's anxiety, rather than on trying to take on the role of a therapist who's going to treat, so to speak, the child's anxiety.
Dr. Keith Sutton, Psy.D: (15:08)
Yeah. Yeah. And then, so.
Dr. Keith Sutton, Psy.D: (15:12)
You know, the way that I oftentimes think about it is that you know, parents are trying to help their kids and help them with their anxiety. Inadvertently they end up accommodating or reinforcing avoidance, which ends up becoming what the problem is. And that is not because the parent's trying to do anything bad or so on. It's more that they're trying to be caring and loving. But it sometimes gives a message that you know, anxiety or negative feelings are bad. We have to do something to get rid of them and talk and so on. So, therefore, you get the accommodating behaviors that end up kind of creating, like you're saying, the systemic effect, which I think is such an important piece because I think that really gets left off. I actually was thinking, as you were telling the story, of a story while you were talking about that. When I was with my daughter you know, in a jump bouncy house or salon when she was young and there was another little girl, probably three or four years old and a kid just bumped into her and knocked her flying and she fell down. She looked up at her mother and this like about to cry and her mom said, “ah, shake it off, shake it off.”
Dr. Keith Sutton, Psy.D: (16:16)
The girl goes, turns around, went boom, right back in again, and I was like struck by how that response. I think the girl also felt attuned to, but also, you know, she shifted in and realized, “okay, this isn't a horrible thing of what just happened. I can pick up and keep kind of moving forward” and so that was really a striking kinda thing just as a parent kinda scene.
Dr. Eli Lebowitz, Ph.D.: (16:37)
I think it's a great story and it's a story that every parent has experienced in one way or another, right? Like your toddler's learning to walk, they fall over, they look at you and there's that moment, you know, if you've had kids like, people know this moment. And there's like this silence and they're looking at you and if you look horrified, they're gonna start crying and it's gonna take a while to calm them down. And when you clap or smile and say “you're okay” then they giggle and they start walking again because they're looking at you and sort of understanding this situation. I think there's a really deep point. And when it comes to anxiety problems to children who have, you know, not just that normative, like sure, sometimes I'm going over or sometimes I'm gonna feel a little bit scared or a little bit anxious. But when you have a chronic anxiety problem and it's being persistently triggered, then all of those small responses, really add up to an incredibly powerful and impactful and important message.
Dr. Eli Lebowitz, Ph.D.: (17:38)
You know, sometimes the way I'll put it to parents is sometimes I'll say, “think of yourself as like a mirror that your child is looking into and they're seeing who they are. And if they're looking in that mirror and what they're seeing is I'm weak, I'm helpless, I'm vulnerable. I can't handle my anxiety. That is what they will believe.” And the worst, I don't wanna say the worst. I'll say the last message. The last message that you wanna give to a child who is vulnerable to anxiety is that they can't handle anxiety. That's such a discouraging and difficult and ultimately impairing kind of a message. I mean, we get this intuitively, we get this for other problems. We, you know, your kid was just, let's say your kid was just diagnosed with a physical problem like diabetes.
Dr. Eli Lebowitz, Ph.D.: (18:33)
You're never going to sit that kid down and say what a shame that you got diabetes because you can't handle it. What an awful message, right? Nobody would do that. You're gonna sit down and you're gonna say, you know, “it sucks, it's a challenge, It's difficult and you're gonna be fine and you're gonna be ok. We're gonna get through this, you’re strong. We'll adjust and we'll be okay.” If your child is vulnerable or predisposed to high levels of anxiety you might not be able to change that innate predisposition but you can definitely change how it's going to affect their lives. By giving them the message, they can handle this, Right? So much of the impairment in the world of anxiety, in all the anxiety disorders, is so much of the impairment comes from that determination, not to be anxious.
Dr. Eli Lebowitz, Ph.D.: (19:31)
That feeling of “I can't handle being anxious” and then you get trapped into this constant cycle of trying not to be anxious. You get more and more impaired and ultimately more and more anxious as well, which is just heartbreaking for all the effort that you're putting into it. The more you fight it, the worse it ends up getting. And so what we try to help parents to do in SPACE is really two things. You know, it's like, it's this whole evidence-based treatment clinical trials, but it's really about making two kinds of changes in how you're responding to your child's anxiety. And the great thing is that neither one of those requires you to force your child to do anything. You don't need at any point through all of SPACE, like whether you're doing it with a therapist or whether you're doing it on your own with the book that you mentioned, Breaking Free of Child Anxiety and OCD which is like a workbook, to work through this treatment on your own.
Dr. Eli Lebowitz, Ph.D.: (20:31)
Regardless of how you're doing it at no point, do you have to make your child do something or make them not do something because it's really all about your responses. So what are these two changes that we try to help parents to make? Well, one of them is to increase what we call their supportive responses to their anxious child, to become more supportive of your anxious child. And this is a very clear definition of exactly what I mean by supportive when we're in SPACE. Obviously, there are a lot of different ways to define the word support. Like lots of things could be thought of as supportive, but in SPACE. I really mean one a really clear recipe for what's a supportive message. It's like this, it's you're being supportive of your anxious child when you're showing them a combination of two things. When you're showing them acceptance, which means you're acknowledging what they experience. You're validating their genuine experience. You're not denying it or dismissing it or trying to tell them they don't feel it. Which sounds funny when I say it like that, but it's what we do so often, you know, kids say it's scary and parents say, no, it's not.
Dr. Keith Sutton, Psy.D: (21:53)
I remember you even in the book kind of differentiated, you know, some parents that are more accommodating in that taking over. Then, other parents are sometimes trying to help out, but more by dismissing, like it's fine, It's okay. They both kinda are on the extremes, you know, what's not helpful to kind of shifting anxiety.
Dr. Eli Lebowitz, Ph.D.: (22:16)
Yeah, exactly. You know, sometimes you fall into this more protective kind of a trap. Sometimes you fall into that more demanding style trap. Neither one is really supportive. You're being supportive when you're showing just simple acceptance. This is what you experience and it doesn't mean I have to feel exactly the same thing, but this is what you experience and I get that. And you combine that with confidence, with a message “I believe that you can handle feeling this way, that you can tolerate it, and you can get through it.” It can be as simple as saying to your child, something like, “I see that this is really difficult for you, or really scary for you, or uncomfortable for you, and I believe that you can handle that.” It's not about what they believe. It's not about what they're going to do, even if it's just, I'm telling you what I believe, but you're holding up that mirror that says, “I do see you and I do understand what you're going through, but I also believe that you can handle it.” Systematically increasing those supportive messages like really systematically, you know, writing them down and practicing saying them to your kid time and time again. That is the first of those two, like big picture changes that we try to do with parents in SPACE. The second is to reduce those accommodations and we don't do it all at once.
Dr. Eli Lebowitz, Ph.D.: (23:35)
You don't have to like, stop all your accommodations overnight, which would be difficult and overwhelming for the child too. And so we worked through it really systematically, you know, let's figure out how you are accommodating. Maybe you're not even realizing all the different ways that you're accommodating. Now we've done research on accommodation across the world from like every, I won't say every, but almost every part of the world, you know, Australia to Asia and, and America and Europe and middle east, et cetera. And everywhere that we've looked between like 97 and 100 percent of parents who have an anxious child report, very frequent accommodation.
Dr. Eli Lebowitz, Ph.D.: (24:20)
So we know this is almost a universal feature, but you're not always aware of it right away. Or maybe you're aware of a few, but there might be 10 others that you haven't even realized are accommodations. So you start just by noticing them, and then you choose one specific thing. And then you plan, how are you gonna make a change in that domain? And you let your child know about it in a really warm, loving, and supportive way and then you start systematically reducing those accommodations. It turns out that if parents can make those two changes, be more supportive and less accommodating to children, they can overcome even a serious, severe anxiety disorder within a fairly brief amount of time. And without even meeting directly with a therapist at all.
Dr. Keith Sutton, Psy.D: (25:09)
Wow. That's great. So I'm struck by what you're saying too, about the way that the parents are kind of reflecting. And it makes me think of Colley’s looking glass theory of self and the idea that we get our sense of self, of how we're reflected in other's kind of faces as they kinda are experiencing us. And it seems like, you know, this would be helpful with kids, with anxiety, as well as even, you know, kids that are acting out. Particularly with the, you know, I do a lot of work with kids with ADHD, and oftentimes, they mess up 10 times more. They're more frustrating and sometimes there's a whole overlap with oppositional defiance because oftentimes everybody's getting so frustrated. And so they kind of get the sense that I'm a frustrating kid and then sometimes kind of respond to that in a reactive way.
Dr. Keith Sutton, Psy.D: (25:55)
But I think that those aspects, even of just like you're saying the acceptance and the confidence. Like accepting mistakes and confidence that they can, you know, they're still a good kid they can figure out or so on. I think it sounds like it actually would probably work both in externalizing as well as this kind of internalizing, you know, situation. That's great, and particularly I would love to hear about any examples or so on. I mean, I was just thinking about, you know, reducing the accommodations and say, you know, you've got a kid who's, you know, having trouble sleeping through the night. They're sleeping in the parents' room or want the parents to sleep in their room. And particularly I know for a lot of parents that oftentimes they feel mean when they're not providing that accommodation anymore and they have a hard time kind of. And particularly oftentimes there's a large reaction from the kids because they were getting that response before and now they're not. And oftentimes that will escalate their distress. Tell me a little bit about that and how you kind of work with that, with parents.
Dr. Eli Lebowitz, Ph.D.: (26:59)
Yeah, absolutely. It comes as a shock to absolutely nobody that when parents do start reducing their accommodations, children do not universally thank them. Right? They don't always embrace them and congratulate them on understanding child anxiety on such a deep level. They don't always do that. Sometimes they do that or some approximation of that, but they don't always do that. Sometimes they get frustrated, they get anxious, and they get upset. They might say things that are really hard for a parent to hear like, “you don't care about me, you don't love me, or this is bad for me.” Or they might try to persuade, or they may simply nag and pester them to a point that the parent feels like they're witts end. And because this comes as a shock to no one we're quite well prepared for that. And, you know, we sort of take it for granted, but this is not always going to be an easy process.
Dr. Eli Lebowitz, Ph.D.: (28:08)
Sure and parents need to be aware of that too. The thing, the one thing that probably more than anything else makes it manageable and easier is actually the thing that I mentioned before, which is that you're not here trying to make your child do something. Why is that so important? Because when you are trying to get your child to do something, you have no escape from the situation until you've won, so to speak. It's a power struggle. It's a zero-sum game, right? Like either you're gonna give up, surrender, and give in and you feel like a loser, failure, and worried about never getting anything done and et cetera. Or you're going to push and push and push until you overcome your child's existence at the cost of a lot of conflicts and often a lot of escalation, and that traps you into the argument, right?
Dr. Eli Lebowitz, Ph.D.: (29:09)
It's like, you come to your kid “do your homework.” “I don't wanna do my homework.” “But you have to do your homework.” “But why should I do my homework?” You have no escape from this, right. Until you get them to do their homework. In SPACE, we make it a really clear point not to get into that struggle in the first place. Because when my plan, as it always is in SPACE, is only about my behavior, I can simply do it and walk away. I don't need to stay trapped. Now you may wanna continue arguing with me but there's no real need for me to argue back because I'm not asking anything of you. And so when you are calling to come to sleep next to me, as you did in the past, it's still hard for me. It's still really hard.
Dr. Eli Lebowitz, Ph.D.: (30:30)
And I need to remind myself that what I'm doing now is the opposite of cruel, it's a gift. In fact, there is no bigger gift that you can give an anxious child than the belief that they can cope with anxiety. It's the best thing you can do about that. And sometimes that's hard just like, you know, holding your baby when they need to get a shot. And it hurts, it’s hard, but it's also a gift, right? You're keeping them safe. You're keeping them healthy. And you're keeping your anxious child strong and healthier by instilling in them that confidence that they can handle their difficulty. So it's still hard, but it's a lot more doable when I know that at least I don't need to force anything on you. I'll give you an example from like sure, take a child with, I don't know.
Dr. Eli Lebowitz, Ph.D.: (30:53)
Let's take a child with social anxiety who doesn't, you know, has a lot of difficulty speaking for themselves and they rely on other people to speak for them. So they go to class and they whisper to the kid next to them to say something to the teacher or they just sit there and never raise their hand. Or they go to the library, and the parent asks the librarian for the book that they want because they're like, “I don't wanna talk.” We go to the restaurant, the parent may put in the order for them. Right? Lots of parents will have encountered this and lots of therapists will have encountered this. Some people like me will have encountered it both as a parent and as a therapist, that's pretty common too. And so we wanna try to work on this accommodation, right?
Dr. Eli Lebowitz, Ph.D.: (31:37)
So I've been accommodating to the parent, you've been accommodating by speaking to that waiter for your child. Now, if we were to make a plan that says, starting tomorrow, we're gonna go to restaurants and you're gonna order for yourself. We would have a problem because what would happen is we would go to the restaurant and then we would say, “okay, remember the plan is you are ordering for yourself.” And the kid would say, “no, no, no, that's your plan. That was never my plan. That was just your plan and I don't wanna order for myself.” And then you'd start persuading them “come on, you can do it. Come on now.” First, you're a cheerleader and then you get angry. You go through that cycle. Now you're annoyed. And you end up storming out of the restaurant, then whatever. Until you try again in SPACE, we would never make that plan in the first place.
Dr. Eli Lebowitz, Ph.D.: (32:25)
What would we say? We would say, “I'm simply not gonna order it for you. And I'm gonna let you know that in advance. I'm not gonna like surprise you with it.” I'm gonna tell you, “I know it's hard for you when have to speak for yourself or when someone speaks to you, I get that. That makes you uncomfortable and I believe that you can handle that.” That's that supportive message. I don't think I'm helping you by always speaking for you. And so from now on, when we go to a restaurant, I'm not going to put in the order for you. I'm not saying what you're gonna do. We go to the restaurant the next time I just need to remind myself not to do it. And maybe you end up ordering for yourself. Maybe you don't, but there's no pressure on you. Maybe you do it the second time that we practice this, or the third time that we practice this. And you know what, even if you didn't order for yourself, we can go home. And I can say, “I'm proud of you for getting through it without my ordering for you. Even if you never order it for yourself, you know what? You handled my plan and I'm proud of that.” When you do it that way it actually becomes a lot more likely that pretty soon the child will give it a try.
Dr. Keith Sutton, Psy.D: (33:35)
Sure.
Dr. Eli Lebowitz, Ph.D.: (33:36)
Right, and this is the important thing. Like, even though we're never trying to directly tell the child what to do at the end. When we do clinical trials of SPACE, what we're looking at in the outcome is actually changed in the child. We want to know, is this child getting better?
Dr. Keith Sutton, Psy.D: (33:50)
Yeah.
Dr. Eli Lebowitz, Ph.D.: (33:51)
And that's what we're seeing.
Dr. Keith Sutton, Psy.D: (33:53)
Righ, so that's, it really strikes me. I mean, particularly thinking about the work we do with kids where there's opposition. Oftentimes we're focusing, on helping parents shift from an outcome orientation to a process orientation. Because I think like you're saying, if they're focusing on the outcome of giving the order, they don't have much power over that. And particularly with kids, they'll let you know how much power you really don't have when you get into those kinds of power struggles. And so that idea of kind of the parent just focusing on what they're gonna do or not do, I think is so significant because that's really where they have to control. Also, I think I like the way you frame it, you know, it's up to the kids. It's their choice, whether they wanna order or not, and really kind of putting it into their hands.
Dr. Keith Sutton, Psy.D: (34:39)
How does this, you know, tell me about the overlay with also parental anxiety and the research. I oftentimes kind of reference sometimes in relation to the systemic work and anxiety. I think it was a Barrett et. all, they did some research using the coping koala and they just worked with the anxious kids alone. They compared that to the anxious kids where they also treated the parents. If the parents had an anxiety disorder and there was no difference in the outcome, but at follow-up, there was a much more significant relapse in the kids with the parents who had anxiety but did not receive some treatment. So I was just kind of thinking, even in this case example of someone, you know, at the restaurant, a parent coming back and saying, “but if they don't eat, that's really bad.”
Dr. Keith Sutton, Psy.D: (35:31)
Like what if they don't, you know, and sometimes the anxiety that comes up for the parent around that. I think there's both anxieties about like, you know, what if they don't eat or so on and for a lot of parents too, you know, there's a lot of anxiety around the feelings and listening. Sometimes the kids go to a negative place, particularly with my adolescence. I'm working with a family and one of the kids, he is worried that if he doesn't do good in the class, he's not gonna get into the right high school. He is not gonna get into college and everything's going to be lost. And he goes to this kind of dark place and the parents are trying to cheerlead and say, “but what about this? Or what about that or so on.” And, part of it is also as we're working, is helping the parents sit with their own distress and kinda being with their kids and their anxiety. So, lots on kinda that aspect, like the, you know, example of like the kid won't, you know, but then he won't eat and the anxiety that the parent might experience around that.
Dr. Eli Lebowitz, Ph.D.: (36:29)
You know, first of all, just acknowledging what you said about the research. You're making what is actually an important point because I sort of with a very kinda rough summary said “okay, we have decades of research treating the parent alongside treating the child. Hasn't really improved outcomes and the big picture that is correct.” It is true that there is data to suggest that when parents themselves are severely anxious treating the parents' anxiety alongside treating the child's anxiety does have some beneficial outcomes. It's just that's a small enough part of the overall population of anxious kids that when you look at the overall numbers, you don't see a strong effect.
Dr. Keith Sutton, Psy.D: (37:14)
Well, it sounds like you're saying too that when you're just teaching the parents, the techniques, rather than actually treating the parents' anxiety it probably has a big difference. Because that might be anxiously trying to get the kid to like, you know, that's irrational thought or something, rather than again, doing some of the acceptance or whatever it might be.
Dr. Eli Lebowitz, Ph.D.: (37:32)
Yeah, but to the main point I think of what you were raising, first of all, and I say this kinda jokingly, but if we were to develop a treatment for child anxiety that only worked for children whose parents are not anxious. Then we would have a somewhat limited product or tool because we know a lot of children will have anxious parents and a lot of anxious children will have anxious parents. I say that as a correlational statement, not as a causal statement. We actually don't know a whole lot about the causal pathways, linking child anxiety, and parent anxiety. But we know that even just at a baseline level, anxiety is so common that lots of kids are going to have anxious parents, even if they're not anxious themselves.
Dr. Keith Sutton, Psy.D: (38:24)
Right.
Dr. Eli Lebowitz, Ph.D.: (38:25)
And that correlation is there. I'm always really careful about anything that sounds like it's, you know, getting a little bit too causal sounding because as somebody that works in the field of parent-based treatment. I'm very keenly aware of the risk of being understood to be suggesting that parents cause children's anxiety problems in the first place.
Dr. Keith Sutton, Psy.D: (38:52)
There's a long history of blaming, you know? And so I'm glad you're pointing that out because that is so important.
Dr. Eli Lebowitz, Ph.D.: (39:00)
Yes. There's such a long and frankly, shameful history of blaming parents for everything, like autism and everything in between. It is not only real and hurtful, but it's also just wrong. It's just false, time and again, empirical data doesn't actually support these theories. Right, and so I like to be really clear that I don't work with parents because I think that they are the cause of their children having anxiety problems. In fact, I believe that's not the case for the vast majority of cases known, putting aside really horrible parenting like abusive, neglectful, and maltreatment. Of course, that's going to have a detrimental impact, but that's not the story for most kids who have an anxiety problem. That's not the story for almost all of them
Dr. Keith Sutton, Psy.D: (39:51)
Many families that I work in with too, if there's a sibling, oftentimes they might have a sibling that's doing well. So I can say, “see, the average parenting is doing well in this situation. It's that this kid needs something different.” And that it's not because you did something wrong, but it's more than that. Again, almost like the kid with diabetes, there's something extra that you might not, you know, be aware of.
Dr. Eli Lebowitz, Ph.D.: (40:25)
Right, and you don't have to give your kid anxiety to wanna help them if they have it either. Right. That's the question of like, “I care about this kid. I love them. If I can help them, why would I not want to? why do I have to be the perpetrator of something bad in order to help my kid?” It makes no sense when you think about it. So I'm just like taking the opportunity to make that really emphatically explicit because it's an important point. But, I mean a lot of parents are going to be more anxious themselves. Sometimes that means that they're gonna go a little bit slower in the process and that's okay. You know, you need to make a plan that's going to work for you. Whether you're doing it alone or doing it with a therapist, you need to make a plan that's gonna work for you.
Dr. Eli Lebowitz, Ph.D.: (41:07)
You also need to sort of build up your own confidence in your child and that's one of the things that happens in SPACE. It starts happening even before you start reducing accommodation, just from making those supportive statements. You know you hear yourself saying to your child a few times a day for a couple of weeks, “I believe you can handle it.” And you may start to feel like actually they can handle it. And then you start working on that accommodation and you remember that. Yeah, it's hard. I'm asking them to do something hard and I have to do something hard too. I'm telling my child, “I believe you can get through this difficult moment”, but I need to get through a difficult moment too. I need them to tolerate and regulate and cope and I need to tolerate, regulate, and cope, and that's okay.
Dr. Eli Lebowitz, Ph.D.: (42:00)
As a therapist, when we're doing SPACE we need to support the parents, just like the parent needs to support the child. Right, and there's a little bit of a parallel process there because this is a hard thing but it's easier to tolerate the stress and suffering when there's a meaning to it. When there's a purpose, you know, to just suffer is bad. You don't need to be Victor Franklin from the book of therapy to realize that when you view your difficult moment with some meaning when it has a purpose, it's a step toward overcoming a really big challenge. When this difficulty that my child and I are experiencing right now is building a foundation for them to live a happier, better life. It's a lot more tolerant and so if you know that you as a parent just cannot accept the idea that your child won't eat at the restaurant then maybe that's not the accommodation to start with and pick a different one.
Dr. Eli Lebowitz, Ph.D.: (43:08)
If it's uncomfortable for you, but you can see it as a step forward and they will go home and eat something then maybe give them a chance because you may be surprised by your child. You know when parents think, “oh, I could never do that to my child.” They're forgetting that there's actually the possibility that it won't even go the way they think. You're sort of assuming that, “okay, so we're gonna have to leave my child's gonna sit there a whole meal and won't eat anything.” But when you actually do back away a little bit and you give them the support and the opportunity, they may actually show you that they can do a lot more than you thought. And one of the things that I hear the most, and that I love hearing the most, from parents who are doing SPACE, or have recently done it, is how we realized as parents that our child is capable of so much more than we thought.
Dr. Eli Lebowitz, Ph.D.: (43:58)
Because when you're always stepping in preemptively or at the first signal of distress to rescue them, you actually don't realize that they can do a lot more than you realize. And I think that that's so important from the child's perspective of themselves as well. You know, there's something great about always being rescued, knowing that there's always someone there who's gonna like come and rescue you. But there's also something really vulnerable about always needing to be rescued. Right, like it's a place of a lot of vulnerability, so it's great that you're there to do it, but wouldn't it be great if I didn't need to be rescued all the time.
Dr. Keith Sutton, Psy.D: (44:36)
Yeah.
Dr. Eli Lebowitz, Ph.D.: (44:38)
Right. Or, to use another metaphor, you know, if your child can only eat when you feed them, then it's great that you are always there to feed them. Right, but it also really limits them.
Dr. Keith Sutton, Psy.D: (44:54)
Yeah.
Dr. Eli Lebowitz, Ph.D.: (44:55)
Because how do I grow to be independent? How do I go anywhere else? How do I feel like I can be okay on my own if I always need somebody there to rescue me or to feed me? Wouldn't it be great if I could actually just handle that for myself, and then I wouldn't need that service? And so I think parents often realize, anxious parents and non-anxious parents, and will come to this realization that actually my child is capable of a lot more than maybe I would've credited.
Dr. Keith Sutton, Psy.D: (45:21)
Yeah. I oftentimes think that that's the greatest gift. Sometimes a parent can give a child that kind of faith or that confidence in them that they're going to figure it out. So even if they're kind of, something's not going so well, you know, the parents, of course, depending on the age of the child involved and kind of steering things. But having that kind of mentality of like, I know you're gonna figure this out, or I know you're gonna get through this will get you on whatever path you need to be getting on there. And that can really help build that kinda perspective of resilience for the kids to really kind of overcome difficulties and take risks and challenges really grow.
Dr. Keith Sutton, Psy.D: (46:06)
I really love this program. I really like too, you know, like you're saying that it's really not focused on getting into a power struggle of the kid of getting them not to do something. But more kind of the parent shifting on their own kind of decisions in their own kind of what they're gonna do or not do, you know, and really kind of shifting away. Oftentimes that will have an effect on the outcome, but not being so attached to the outcome because sometimes then it will be disingenuine. And to that aspect that you're talking about of the parent being willing makes me think of an acceptance commitment therapy. The idea of, you know, being willing to go toward, go through distress or sitting with uncomfortable feelings to go in the direction of one's values.
Dr. Keith Sutton, Psy.D: (46:55)
So that connection to the values or the meaning allows the person to kind of sit with that distress to kind of move in that direction. Which might be sitting there while their kid's not eating or, you know, sitting there while their kid's kind of going to that negative place or whatever it might be and that's hard. It's the muscle built, you know, and I think like you're saying that parallel process of also being accepting and understanding that it's hard. While at the same time also having the confidence that the parent can do it and kinda build that.
Dr. Eli Lebowitz, Ph.D.: (47:30)
Yeah. You said it perfectly.
Dr. Keith Sutton, Psy.D: (47:34)
Great. Well, this is wonderful, and anything that you're working on now? When did you put out the book for the parents? I recently got it and it's great. I'm just getting up to the accommodation part now.
Dr. Eli Lebowitz, Ph.D.: (47:48)
That's awesome. Let me know when you're through and what you thought. It came out in January, so that's pretty new.
Dr. Eli Lebowitz, Ph.D.: (47:58)
Yeah, we're recording this in April. So it came out and was sold out on the first day that it came out. It is back in stock so people can find it and get it as an audiobook and as an ebook. They make it really easy to find, you know, in terms of things we're working on now. There are a couple of things that maybe are of interest. You know, one thing is that we're continuing to build the evidence base for the first base. So we've completed multiple randomized control trials. We're doing a randomized control trial right now where we're also using brain imaging both before and after treatment using functional magnetic resonance imaging, or fMRI. Actually, to learn more about what is changing in a child's brain, as these changes are happening at the family level and their anxiety is improving.
Dr. Eli Lebowitz, Ph.D.: (49:02)
And I think that's really fascinating and we'll be sharing some of those results in, you know, research articles in the near future. Another area that we've been working on is actually some expansions of SPACE to additional areas that lend themselves to this kind of approach. You mentioned some of the attention problems. For example, there are a couple of areas that we have been already working in such as what DSM calls ARFI or avoidant restrictive food intake disorder. Normal people call it very picky.
Dr. Keith Sutton, Psy.D: (49:44)
Sure.
Dr. Eli Lebowitz, Ph.D.: (49:45)
And, you know, ARFI was a natural for us for a couple of reasons. One is we were kind of already seeing that except we were labeling it food phobia, or some anxiety label, but actually we realized we were treating ARFI. And once we realized that, you know, it really became apparent that this was another area that lent itself to this kind of approach because it is heavily accommodated. You know, parents are so motivated for their child to just eat.
Dr. Keith Sutton, Psy.D: (50:18)
Yeah. Right.
Dr. Eli Lebowitz, Ph.D.: (50:19)
There are a few things that, you know, every parent wants for their kid, but certainly one of them is that they'll eat. If my child doesn't eat, you'll go to great lengths and this can trap you into another cycle of accommodation and also of impairment. The impairment really comes from this limitation that, you know, maybe my parents will accommodate me like this, but nobody else would. Right, and so how can I go anywhere else to eat? And we as a family, can we go anywhere? Can I go to play dates and sleepovers? And so you get a lot of impairment. In a development that was spearheaded by a former postdoc and now a colleague of mine, truly took the SPACE model and applied it to ARFI. With some small adaptations and some additions because there are some unique characteristics to ARFI that are different but there's also enough that's shared, we've published the clinical trial data on that. I think that's exciting. We have an adaptation of SPACE that we're currently doing a clinical trial for working with parents of adult children.
Dr. Keith Sutton, Psy.D: (51:34)
Oh Great.
Dr. Eli Lebowitz, Ph.D.: (51:35)
And, in particular, adult children who are not transitioning to independent functional adults.
Dr. Keith Sutton, Psy.D: (51:43)
Struggling with launching
Dr. Eli Lebowitz, Ph.D.: (51:45)
Yeah, exactly. People often call it failure to launch.
Dr. Keith Sutton, Psy.D: (51:50)
I mean, this is perfect for that cause. Oftentimes I'm helping parents in those situations to say like, you know, can't make you do anything, but I can't necessarily support you in these ways. So I'm gonna kind of step away from giving money or doing whatever it is that's kinda potentially, you know, enabling. I don't really like that word enabling, but it's those accommodations and trying to help out. But sometimes scaling back, not as to be mean, but just to say, “this is the way that I can feel okay about not contributing to this problem.”
Dr. Eli Lebowitz, Ph.D.: (52:21)
Exactly, I mean if I, as a parent, am so concerned about my adult child's function and you know, people talk about young adults. I don't say, young adults. I just say adults because I worked with parents of people who are absolutely not young adults. They're just adults and you know, this doesn't have like a natural endpoint. There's no expectation for it.
Dr. Keith Sutton, Psy.D: (52:42)
Yeah.
Dr. Eli Lebowitz, Ph.D.: (52:43)
And so if I'm so concerned, you know, I need to find a way to not be providing for you the optimal environment in which to not function. Like it just doesn't make sense that I would be doing that, but it's really hard for parents to make any kind of change. And so we have a version, you know, of SPACE for working with those parents and, you know, kind of gradually extending into other areas.
Dr. Keith Sutton, Psy.D: (53:15)
Perfect. Well, this is wonderful. Thank you so much for taking the time. It's great to hear about the model and it seems like such a caring model. Also, you know, really kind of that aspect of the providing that parallel process of the support and confidence for the parents and helping them provide that for the kids. And again, in a way that is really kind of self-directed and not, you know, pushing up against power struggles. It sounds like that's some great kind of things in the future as you're kinda expanding it to different areas. So I appreciate you taking the time today, and telling us more about the model and it sounds great.
Dr. Eli Lebowitz, Ph.D.: (53:57)
Well, thank you so much for having me on.
Dr. Keith Sutton, Psy.D: (53:58)
It's been a pleasure. Thanks a lot. Take care. Thank you for joining us. If you're wanting to use this podcast or continuing education credits, please go to our website at therapyonthecuttingedge.com. Our podcast is brought to you by the Institute for The Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco bay area. IAP provides training for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. For more information, go to SFIAP.com or call 415-617-5932. Also, we really appreciate the feedback. If you have something you're interested in, something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us. We're always looking for advancements in the field of psychotherapy to help in creating lasting changes for our clients.