Muniya Khanna, Ph.D. - Guest
Dr. Muniya Khanna is a clinical psychologist specializing in CBT for anxiety disorders and OCD. Dr. Khanna is a pioneer in web-based mental health research for anxiety disorders. In partnership with her mentor, Dr. Philip Kendall, she developed and tested Camp Cope-A-Lot. She is currently conducting 2 large-scale clinical trials, funded by NIH and NICHD, focused on the dissemination and implementation of evidence-based treatments for anxiety in urban public schools. Dr. Khanna has authored numerous books and research publications, has been on faculty, is on the review board of journals, and boards of the American Psychological Association. She is Founder and Director of the OCD & Anxiety Institute in Pennsylvania and Research Scientist at the Children’s Hospital of Philadelphia. |
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. Sutton: (0:21)
Welcome to therapy on the cutting edge 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 interviewing Dr. Muniya Khanna, a psychologist researcher, teacher, and author. Muniya is a specialist in childhood anxiety, and has been involved in a number of research studies on treatment using cognitive behavioral therapy, also in research on pediatric OCD. She has worked with Dr. Phil Kendall to create a computerized version of his Coping Cat program that is used with children, with anxiety in schools, and many other contexts. She's a founder and director of the OCD and Anxiety Institute in Pennsylvania, and is a research scientist at Children's Hospital in Philadelphia. She's also in the process of publishing her second book, which will be on resiliency. Let's listen.
So the interview. Welcome Muniya. Thanks for joining us today.
Dr. Khanna: (01:21)
Thanks so much for having me.
Dr. Sutton: (01:23)
So I've known you for some years now. I actually did a training many years ago with an exposure with response prevention for OCD. And then was given your name as a consultant for working with kids with OCD and pediatric anxiety. And you've been my kind of go-to person over the years to talk about difficult cases and such. Also you were involved with developing Coping Cat, the program for kids and the computerized CBT program and lots of other stuff.
Dr. Khanna: (01:57)
Yeah I can kind of walk you through the background. Maybe even before we had originally met, so I started out, I was so lucky, you know, I think just sometimes the universe sort of leads you in the right direction. And it did, for me, I met Marty Seligman as an undergrad and actually that was, my first research internship or externship, what you'll call that. And it really just changed everything for me. I was a pre-med, sort of heading in that field. I knew I wanted to help people, but this was really life changing for me.
We learned that the study I was a part of was the study where they were testing out CBT, brief CBT in schools. And they were comparing schools with this brief CBT against schools that were not getting this CBT. These were short groups, you know, 35 minute groups. And I think over the course of eight to 16 weeks, we were seeing huge changes in how often the kids would meet criteria for depression, not just at the end of the groups, but even long-term compared to the other schools that never received those groups. And it was for me just the amount of impact that words were having, words that were offered that were relatively low cost in a sense of for public schools. Certainly to be able to offer something, and in just eight weeks or 12 weeks or 16 weeks, depending on the program that they were seeing such change, long-term change; changes in the way kids were functioning globally, not just with depression ratings.
And that was it for me. I said to myself, you know, everybody should know about this. And then after meeting Marty Seligman and his great team, Karen Reivich and Andrew Shantay at Penn, I was, again, lucky to be able to work with Phil Kendall. Phil was the author of the Coping Cat treatment. And the Coping Cat was the, what is now the standard of best practice for psychotherapy in children with anxiety. It's a 16 session CBT program. Phil was my graduate mentor. I learned my work in anxiety in kids. I learned everything from Phil and his team at temple. And then Phil and I became collaborators and friends in that graduate school process. And I said to him, I think you know, this was now 2001, 2000. And I said, Phil, technology is going to be big in mental health and it's such a great way to reach kids. And it's such a great way to reach families and maybe even help standardize some of the quality of care being offered. And maybe a way to reduce the friction between, you know, we talk so much about how to bridge the gap between research, world data, and community world data, right. We know that kids are getting treatment, even the ones who are getting treatment in the community are not getting evidence-based treatments. And so we're not seeing the same outcomes.
Dr. Khanna: (06:10)
So first, the problem is that there's not enough people getting treatment. The next problem is that those who are, are not getting the kind of care that is leading to any real measurable change and how to bridge that gap. And for me, technology was a clear direction to go for psychotherapy. And at that time, there wasn't you know, iPhones there were not really iPhones. There were no smart phones. There were flip phones and of course the internet was still, it was there, but it was not what it is today, you know? So I had some background, my father's a technologist actually, in his way, had sort of started that path early. And so I learned from him young and became very sort of computer comfortable. I'll say, I'm not an expert, you know, a coder or anything like that, but I'll say that I became very comfortable with technology early on. And so it was a really easy fit for me and Phil, being really progressive and supportive and excited by the prospect. We wrote our first program together, Camp Cope-A-Lot. Camp Cope-A-Lot is a 12 session online, now it was on a DVD at the time, but now, it doesn't work anymore because the flash doesn't work, but everything is now online, cloud-based and still very much alive. And you know, it's a quick fast forward, but schools are calling me daily to implement Camp Cope-A-Lot for their remote support system.
Dr. Sutton: (08:16)
Yeah, everything with COVID right now. So it's online, that's good to know.
Dr. Khanna: (08:21)
It's online, you know, copingcatparents.com is still the hub of where we're keeping all of our programs and, you know, again, very grateful that it was there, that we had this program ready to go when COVID hit, and we had data to support it. And so very excited that we're sharing this with school districts and with families, families are able to buy it too, so parents can buy the programs. Anyway, so that was 2002 when we wrote Camp Cope-A-Lot. And we launched it, it became a research study that we did. I finished in 2008 after that, again, very lucky to start working with Marty Franklin and John Piacentini in the OCD world. So Marty Franklin gave me my first job after my internship, or actually it was my post-doc at Columbia where Marty came to visit me and offered me my first role as a faculty member at the University of Pennsylvania. And so, so exciting, it was a dream job. I had gone to Penn as an undergrad and sort of came full circle back, and Edna Foa was there. And so I was really lucky again, to be able to learn PE from Edna, learn about exposure and response prevention from Edna and from Marty, and Marty is such a brilliant clinician. I just fell in love with the work, the EXRP work.
Dr. Sutton: (10:08)
EXRP being the prolonged exposure, then exposure, response, prevention?
Dr. Khanna: (10:13)
Correct. So EXRP exposure with response prevention, that's the treatment that we've found to be most effective for OCD. And Marty is just so brilliant in really using that approach with kids. And that's where we did our work. He had already started this work called the Pots trials. It was the pediatric OCD treatment study. And so they had done the first randomized trial evaluating CBT with exposure and response prevention compared to medication, which was an SSRI, compared to the combination of both, versus placebo. It was a multi-site trial, the first to be done in kids. And he had published that. And Gemma and I came on board when the second trial was being started. And then I stayed on to evaluate and develop the work on Junior OCD treatment, which then we started calling that Pots Jr. And really what that was, was working with kids between the ages of five and eight, and translating the same approach, but for a younger population, and that involved parents a lot more. And so I stayed and we published the results of those trials while I was there. And it was such exciting and fulfilling work to be able to see these treatments that I could see for years working in session, that we could show now that, you know, we have the data to say, yes, actually it's working and it's working as good as medications in many cases. And it's, you know, maybe even longer term better to do treatment with CBT than without CBT for longer-term impact. So that was so rewarding.
Dr. Sutton: (12:34)
Doing exposure with response prevention with CBT? Okay, combining those two, as well as-how did it do with and without the medication?
Dr. Khanna: (12:43)
Yeah, so the results were that medication alone was as effective as CBT with exposure alone. So either one alone was effective. But when you combine them, it was more effective. And when you looked longer term, out to a year, that it seemed that CBT was having longer term impact, and that, you know, I'll say this, not through data, but through what we've, what we've come to understand is that after about a year, some changes might need to happen on the medication side. And so we don't have the post one year data on that. I think that will be coming too, but, um, but basically it was, you know, the punchline was that if you haven't already started medication, that perhaps CBT with exposure and response prevention would be the one to try if you had a child with OCD, because that is a low side effect you know, long-term impact potential to be all they need to benefit and to come to, you know, a level of symptom severity that was not significantly interfering in their lives. So again, so fulfilling for us to say, yep this is working, these are words, these are things we can share with low negative side effects. And the difficult part of course about therapy is that you have to find someone who knows how to provide it, and you have to have the time to be able to participate in it, and you have to have the resources to be able to pay for it, or insurance that will be able to cover it. And all of those things are tremendous barriers through mass scale. And we've seen that bridge that I talked about earlier is still very much a wide gap. And that sort of takes me to where I am now. I think that's what brought me to where the work is today, which is really just to disseminate this in more, more ways and more delivery methods, and simplify as much as possible, so that maybe paraprofessionals can also be as effective as highly trained professionals to support kids on the front lines a bit more.
Dr. Sutton: (15:40)
Tell me more about that, what kind of things are you doing?
Dr. Khanna: (15:43)
So I'll say first, I'll sort of categorize it. So if I say as a whole my job, you know, my career focus has shifted really from where I was trying to be part of the team that was evaluating and making sure these treatments were working, making sure we have the data to support it, making sure, you know, this is what we wanted to recommend. And now that we've sort of gotten to that point where yes, you know, we know a few things, we know there are things that can help now; the job has kind of shifted to how do we get these tools into the hands of families who need it? And so now, if I say that that is sort of my umbrella focus, I've kind of taken it in a few different directions. One is in writing much more. I'm trying to do a lot more direct to consumer writing as opposed to research writing, you know, which is where things were in the previous 20 years of my life. And then moving that to, you know, I've been writing, of course the first book was called the Worry Workbook, which is a workbook designed for kids to learn and use some of these strategies to help them manage stress and worry. And it's designed really for parents to work with their children and that the workbook is sort of something that walks them through the steps. And so that was a first pass of writing to consumers directly. And that book now is being used in some school districts as well, which is wonderful. So again, more tools out to the public.
Dr. Khanna: (17:35)
The other book that you mentioned is the Resilience Recipe and Phil Kendall, and I are authors on the Resilience Recipe. It'll be coming out in November. And what we really wanted to do is, again, speak directly to the parents, you know, that again I'll back up a little bit, in the time that we were doing that research and the time that we are in today, the sense of urgency has multiplied so greatly. You know, I don't even know how to wrap my head around it really. The numbers of kids who are struggling, obviously, you know, we've seen the news of the doubling rates of suicide in kids under 24. We've seen the trajectory of anxiety and depression and the COVID pandemic has now taken those numbers and sort of blown them out of the water. I don't have the numbers exactly to give you right now, they're being collected, but I think what we can say except is that I'm sure that they're extraordinary. And I think that the need for action, and the need for people, you know, to become empowered themselves is so important. And I got very frustrated, Phil and I both got frustrated because what was happening was we were speaking to other researchers, we were, I mean, it was great. We were talking with schools and hospitals and clinics. And so places that had staffed, you know, experts and clinicians, they were using Coping Cat and they were using the exposure and response prevention. So that was wonderful. That was a great big step for the first round of things. But, you know, this round has to be so much more active and so much more in the hands of everyone. And the frustration was that partially it was our fault. We're here not really talking to the public. We're not really on TV. You don't see that many expert clinical psychologists on social media or on television or radio. I think you are then getting people who are maybe interpreting the work, or maybe talking about their own life experience, or maybe that they've heard, they've become sort of students of this enough that they're now communicating and being effective communicators have reached audiences. And when we can hear that, yes, they're saying some things that are definitely good, they're definitely leaving out a lot of things that need to be included. And so I felt sort of personally responsible. And so Phil and I...you know Coping Cat has been given to the people, it's in the hands of the people who we wanted it to get to; in the hospitals and the clinics, but now we really need to get this to the hands of parents.
Dr. Khanna: (21:03)
And so the resilience recipe is really using the components of cognitive behavioral therapy for kids, with anxiety and depression, and combining it really to be, David Barlow would use the term, trans diagnostic. Not really just for kids with anxiety, not really just for kids with depression, but using the principles that have worked for those populations to make those principles available to parents, and make the strategies practical and something that you can do at home. And something that I'm hoping that parents can feel empowered by, because then they can handle a lot of these conversations. In fact, that's one of the end of every chapter has key takeaways, but throughout there's conversation starters, because it's designed to help that conversation. You know, what do I say to...so a top 10 list on a blog is only so effective if I know how to present it or how to even make sense of it. How do I know when to use it? How do I know if that even applies to my child? So what we've tried to do is make it clear where those top 10 tips came from in terms of here's the principles behind them. And then here's how you would talk about it. And here's just even an example of a conversation starter.
Dr. Sutton: (22:40)
Yeah. Kind of like the principal driven kind of trans diagnostic approach, that's being able to cover numerous issues. And when the parents have the principles, then they can kind of maybe have a little more confidence or a little more ease in discussing that and having conversations with kids rather than just kind of going off the information itself and not really understanding kind of the principle it comes from.
Dr. Khanna: (23:04)
That's exactly right. Because I, again, I really tried to avoid a list of top 10 tips when I wrote this, because I really wanted to make it really understood and then be able to create a lifestyle around it, not just sort of a short-term fix of a problem, you know?
Dr. Sutton: (23:30)
Well, that's pretty true about the idea of resilience. So that's always been a great interest of mine because one of my specialties is around teenagers and there's all these different things that we can do to help them through their childhood, through their life. But I always wonder, in my own experience and others that I've known that have gone through difficult things and come through and been able to go on to be successful and other people that struggle and don't, and really kind of have a hard time in life. Yeah. I mean, how is it...it's really kind of hard to figure out what leads that person to overcome those obstacles and go on to thrive, while others get really kind of stuck. And particularly too, even now that I have my own children, really looking at how do I help influence their values and giving them tools and so on. But also having that kind of resiliency and overcoming obstacles that might come in their lifetime or so on. So yeah, I'd love to hear your thoughts on just kind of resiliency and I know, Marty Seligman, and kind of where some of your work was starting was a lot of positive psychology resiliency. I would love to hear your thoughts on those.
Dr. Khanna: (24:40)
Yeah. And definitely influenced by Marty Seligman, Karen Reivich and Andrew Shantay's work on resiliency. But I'll say that what we might do a little bit differently, or maybe not differently, but maybe in addition to some of the principles that they speak to, we really incorporate a lot of the principles about anxiety that we understand, we understand the stress, that fight or flight cycle very well. And, and it's very core to a lot of our coping strategies, meaning that when somebody is anxious, that your response is not just because of the situation you're in, you know. I have a challenge, I have a test, or I have, you know, let's say I'm worried about getting COVID--the circumstances there. And a lot of times we really, we just assume that that circumstance is creating that stress, but what we understand of anxiety and the source of all of our anxieties is that our body is so pre-programmed to scan for danger and to over-interpret danger, just in protection. You know, we call it the caveman brain for kids, or the bully as John Marsh would have put it. We use that language, I think a lot more than maybe we did with the resiliency work when we were working with kids that were more prone to the more depressive response to stress. So what we did was really married the two being that they are really similar in so many ways, even though they might be manifesting in different ways. But that's sort of a digression I'll say, is that my take on resilience is that, this is very much the crux of the book that's coming out. So I'll sort of just try to give you the bullets. Our theory about what it takes to develop resiliency in kids is an approach that really combines four key concepts.
Dr. Khanna: (27:16)
And those, so I'll just take one at a time. The first is the need for a development of awareness and of compassion. So awareness and compassion is one of our first main blocks. You know, the main foundation of being resilient is to have a great amount of awareness of your own physical response, your self-talk, or your inner voice response, your tendencies in terms of behaviors and where that comes from. The insight, and that understanding is such a powerful tool in being able to counteract, it gives you the opportunity to observe. And then that observation gives you the distance between the feeling that may have come instinctively and what to do next. And so the first key component I think to help is the need to help them build that awareness.
Dr. Sutton: (28:27)
Mindfulness that kind of, detective kind of look at what's going on, that's kind of leading to those emotions or behaviors or such.
Dr. Khanna: (28:36)
Yes. Right. And we do, we use the same kind of cognitive behavioral strategies like the detective or listening to your inner voice or listening to your self talk. So we use some of those and it all fits in that same category of mindfulness, of being able to really slow down and become more aware. And that, like I said, it's such a powerful tool in giving us control over what happens next. You know, we want to be in creation of what happens next, as opposed to just being responding to whatever situation we're in. And that's true for when things go badly or when things are challenging, you know? So that's resilience again, it's a sort of a universal strategy for both types of challenges, both anxiety provoking, and those that are about loss and grief and loneliness.
Dr. Sutton: (29:42)
It is kind of like moving from being reactive to being responsive, rather than just reacting to something kind of deciding how do I want to respond to this situation?
Dr. Khanna: (29:51)
Exactly. And so we teach the worry cycle, you've seen me draw that cycle so many times, in workshops and, with kids, that drawing is just a map. It helps you sort of start mapping and that map gives you then a visual and now something actionable, something that you can get a distance from enough to do something about. So, that's sort of the first key component. We'll talk about it in the book.
Dr. Sutton: (30:22)
The compassion part. Can you speak to that? Is that like the coping thoughts?
Dr. Khanna: (30:28)
No, not yet. Actually, I think the compassion part is about observing them without judgment, as we sometimes feel, because I'm anxious, I'm weak, you know, because I reacted badly, it was an error, it was me being just too vulnerable. I'm not this enough. I'm not that enough. I need to be...
Dr. Sutton: (30:51)
Non-judgmental. You know, noticing rather than judging.
Dr. Khanna: (30:54)
Yes. Noticing rather than judging. And, and I spend a lot of time talking about perfectionism actually. I'll say that, I think that's one of the biggest challenges even though, of course, COVID and sort of the uncertainty of our future is going to trump all of this for a little while. But I think a lot of what our kids were struggling with was just this perfectionism culture. You know, this culture of you will have a good life only if you, and then all of these conditions. If you are hardworking enough, smart enough, thin enough, funny enough, have enough friends. So then our kids are getting into this checklist of how am I doing on all of these things. And as you know, our brain will never help us out in that area. And also just life is usually, you know, of course I'm mediocre compared to a million other people. So if I really start measuring this out, it's always gonna turn out not great and easy for the mind to start heading in that direction of I'm not good enough.
So I think the idea of giving parents the language to...we have to be a filter almost to that message, the fact that you are seeing messages and hearing messages in school and online and on shows about what it takes to be happy. I think those conversations have to be had early and often. It's not that we are going to change society by saying ignore all of those things, put away your phone. That's not how it's gonna work. It has to be through conversations, you know, conversations about what makes you worthy has nothing to do with any of those things, and sort of the meaninglessness of the things that we say we've kind of started to say are meaningful. And so we want them to have that space to be compassionate about failure because you can't really approach and be resilient and bounce back from failure when everybody around you is saying failure is not okay. So we're sort of expecting kids to just, you know, Hey, you've got these SATs that I have told you since the fifth grade that are the benchmark or the gateway to the rest of your life, but don't worry about it. You shouldn't stress about that, you should be resilient. And how can we get more grit, you know, can we get you more gritty now? And I think it's really unfair if we're not having the conversations to take apart your intelligence is not measured by this test. I know, you know your worth, your value in society is not measured by this test. Where you go to, what sweatshirt you put on is not the sign of what I think of you. And if anybody does that, it's their loss or their shortcoming of thinking through this more, you know? And so, not to over-simplify, but again, the conversation about this, communicating our values as opposed to our fears is something, I think we reiterate a few times in the book, when it comes to helping build compassion.
Dr. Khanna: (34:27)
Okay, so then the second part. So the second part, and this is where those coping thoughts come in, this is about cultivating a mindset of growth and flexibility. That's where we spend a lot of time as a major next component required to build resilience. We want to help them see how their thoughts and their behaviors are influencing how they feel, and that it's not just, again what they're experiencing in the world, and having a mindset that there is no such thing as failure, because I'm never gonna stop trying. One opportunity ends or closes, another will come, I will pursue another. And that rejection is a learning opportunity. It's a temporary delay of what comes next, or it's just a part of the path to what comes next, opportunities to learn and grow. And the fact that I talk about it as having a superpower. You know, the fact that we have the ability to reflect is kind of our biggest, it's our kryptonite. We reflect and we think of all the things we did wrong. We think of all the things we could have avoided, and then start planning how to avoid them in the future. So in a lot of ways, we think our mind is just always doing the wrong thing and just sort of a pain, but actually it's our superpower. It's actually the thing that helps us the most, we're surviving because we get to innovate and problem solve and learn and grow and change and love and give and share. And so we talk about how to really build up that focus, the focus on the creating and the doing and the learning, as opposed to the reflection of what didn't go well. And that's where we talk about coping thoughts and thinking, deciding which thought is the one that is actually the most useful as you move forward.
Dr. Sutton: (36:40)
Okay. That kind of awareness, compassion, and how did you phrase the second one again?
Dr. Khanna: (36:46)
Cultivating a mindset of growth and flexibility.
Dr. Sutton: (36:51)
Like growth mindset.
Dr. Khanna: (36:53)
A growth mindset. Of course, Carol Dweck absolutely has influenced this. And the work in flexibility, you know, influenced by many as well, Ana (inaudible), Marty Franklin, and many others, that when we become too rigid about exactly what we expect and exactly what we should do, it puts us at risk of again, being too focused on what didn't happen, as opposed to growth. And then this one is the big one, I'll say for us in the anxiety world, is the third one, which is adopting a lifestyle of approach. So in our research, and as you know, we call this exposure. Exposure is such a terrible word. It sounds like something you wouldn't want. But what I like to call it, approach more than exposure, I actually think approach might be more accurate.
Dr. Sutton: (38:01)
We're trying to do the opposite of avoidance, which means approaching.
Dr. Khanna: (38:06)
Yes. And an openness to that approach. So this is where I think a lot of clinicians, even though they are well studied in a lot of this, I think a lot of times, even good clinicians really hold back from doing this real push towards approach in the context of therapy. And I think we do this at home too, meaning as parents, I think, you know, Eli Leibowitz, who's done some incredible work at the Yale Child Study Center has just recently done a study on, his work has shown that parents in therapy learning, how to not accommodate or learning how to encourage approach is as effective as having a child in therapy. So that's how powerful first, how powerful a parent's role is. Second, how powerful that shift from avoidance to approach is when it comes to building resilience and building that. We always say, I just wish they were more confident. I wish they could handle stress more. And this lifestyle of approach is something that we spend a lot of time talking about. So it's not just making sure they pet the dog, if they're afraid of the dog. It's also just sort of saying, I don't know who's going to be there, but let's go anyway. I don't know who's going to be at camp. Maybe you're going to be horrible at baseball. I don't know, but let's just sign up anyway.
Dr. Sutton: (39:59)
But I'd love to hear that research too, because I don't know if you know, but I do a lot of family work. One of my main focus is working with family systems, particularly that piece.
Dr. Khanna: (40:09)
Yeah. And his work is fantastic. And he has some great books that I wish I had the, the references to give you right away. But what I'll say is if you google Eli Liebowitz, or look him up on Amazon, his books are terrific. And really spend a lot of time talking about how families can encourage approach. And he might say reduce accommodation.
Dr. Sutton: (40:36)
As families are trying to help out, sometimes they're reinforcing avoidance. So it's not out of malice or anything, they're just trying to help them.
Dr. Khanna: (40:45)
Not at all. And a lot of times we're just trying to keep them functional. I tell my parents all the time that I get it, he didn't want to go out of the car to get to the, you know, baseball, let's use that as the example, and you need to get to your daughter's, you know, doctor's appointment and you can't sit there. So, okay. Let's just skip baseball tonight. We got to go to the doctor's appointment, or you got to sort of push things along, or your stomach is feeling sick, but I have to go to work. Okay. Why don't you just stay home today? And it goes from zero to 90, very quickly in terms of becoming interfering. And that's usually when we'll hear that things are a problem, but it's not just that parents are sort of...I think it's unfair to label all of it as helicopter parenting or overprotection. I don't think it's all that, I think sometimes we respond to our kids. Some kids who are already sort of in approach mindset already, if you let them skip a day of school because their stomach hurts because they're nervous for a test, that's not necessarily going to translate into a lifetime of stress and test anxiety. And so a lot of times we're just sort of, we're playing it by ear, we're reading their response. And we're kind of trying to figure out, where do I draw the line? And sometimes it's just harder to know. And sometimes our kids are asking for things in a way that sounds very reasonable, but is actually not the right way to go. And again, that's why I think understanding the principles really helps because it helps you kind of navigate, how do I know? Is this the time I have to hold the line? Or can I let this one go. She doesn't want to go on that sleep over, is she anxious about sleeping away from me, or at home? Or is it that she's not particularly fond of this group of friends that is going to be there and is that kind of okay, or is it social anxiety, and so you want to now understand a little bit about what the decision-making can look like. And I think that's, again, understanding the principles of avoidance and the function of avoidance. It can help you kind of map out, is this just a one-time thing, certain group of kids, maybe this is fine, you don't have to go. Or do I see, oh, this is a pattern of every time there's a group of kids that they're not as comfortable with that they choose to not go. Maybe I should encourage more of this. You know, maybe we should try more of this. Maybe I should push a little more. So really building that lifestyle of approach is such an important thing. And certainly if you know that they're avoiding something specific, we also talk through how to really push on those more specific things. So if there is something like test anxiety, or if there is something like social anxiety or a lot of anxiety around new social experiences, we do also discuss how to support kids and practicing that in step-by-step, as we would in an exposure world, we would say do it slowly in small steps. So it's manageable to move to the next step. So we do talk about that, but I think we also talk about it more generally, too, in terms of this approach lifestyle.
Dr. Khanna: (44:21)
And then the last one is kind of an easy kind of quick one, which is not easy to implement or easy to summarize, is that our job is as parents, we aren't teaching something. We aren't, we are teaching, but we are not. Let's say, we, by doing and saying any of these things, we are not the change agents. You know, we are just guides. We are supports. And that's really the thing we can do most that's where our power is. I think most valuable is how to give compassion, how to give support, how to appreciate, our kids don't hear enough. I think about what we appreciate about them, and again, to no fault of anyone, it's not that we're a particularly harsh society that way, it's just other than saying, 'I love you, have a great day.' Things get busy and we keep moving and it's hard to say, 'oh my God, that was really funny. You know, you cracked me up, that was really funny,' more often than, 'oh, good job that you did so well, you're a really good math student,' you know? And so of course both should be appreciated, but just generally coming at, I like to have a five to one ratio of saying things that are positive, noticing things that are positive. And then that makes your one thing that you would say, 'Hey, you know, why don't you try this?' or, 'Hey, you know, it seems like you're having a hard time with this, maybe we could do something to help.' That one correction or that one teaching moment can become more powerful because you're not, you know, you haven't become part of the anxiety cycle, then you're part of the security piece, right? You're aware things go to feel good. And that is, I think so powerful. So, you know, we've labeled that section, the ultimate gift of security, and it's not really security in that oh, you can make sure that you're never in a car accident, I wish we could do that. But security and knowing that you're always there and that there's nothing they can say or do that would change how much you believe in them, how much you value them, how much you of course love them. And then again, over and over in as many ways as you can, to a five to one ratio, and I would say in the COVID time, when we're seeing maybe more irritability, maybe more withdrawal, maybe a little bit more of regression, even, Not a little bit, I mean, in some cases, a lot of regression, of having been isolated for so long and having routines be off for so long, it's making everyone, including adults, really lose center and feel a lot of angst and feel a lot of agitation and making all of us a little bit too irritable. In this world, I would say double that, you know, make it a 10 to 1 ratio rather than saying, I need to discipline more because they're just acting out and this is not okay in my house. I would say support, guide, encourage, tell them their impact, tell them they're valued and meet them where they are. Play a video game, even though you're worried about too much screen time with them, invite their kids, have their friends on a zoom call so that they can have that friend contact. But even if it's more than usual or seems like not much, right now I don't think there can be too much love.
Dr. Sutton: (48:30)
I think, too, that's the proactive part of parenting that sometimes is more effortful to kind of shift our attention in that direction. Sometimes we get more into the reactive parenting and just kind of taking stuff away or stop doing that, or don't do that rather than, you know, having to reinforce like, oh, you're doing that really well. We're trying to get that to happen more. I think about it too, that kind of makes me think when you're talking about this, as parents, as guidance support that, you know, I always think about one of the greatest gifts that parents can give to their kids is their faith in them, even though maybe they had a tough time at school, like they know they're going to make it through this, they're going to do all right. Or even though maybe this happened or that happened, they can see that in them that they're going to make it through all these things that kind of really can instill that kind of resiliency to not you know, like every kind of bump in the road or kind of wave is going to be the end of it. Typically I do a lot of work with kids and families with ADHD and adults with ADHD and shifting to that, you know, oftentimes kids with ADHD that mentioned that five to one, they get in so much more trouble and they end up-we really have to increase that by a lot more. And really the goal often times with kids with ADHD is just been to get them through their childhood without a great deal of shame. Building that resiliency, because that's one of the things parents and adults with ADHD struggle with.
Dr. Khanna: (50:02)
One hundred percent agreed. I could not, I would underline that a million times. Absolutely. And I think you put it so well, you know, making it through childhood, that their childhood should be an experience of unconditional love. And that feeling of course, again, we're approaching challenges where we're encouraging approach. So it's not that we're saying, you know, we're not anything we're not challenging, we're not growing. We pursue all of those things. But with the understanding that we believe in you, you don't have to fit the mold of everything else, everybody else, that you are enough exactly as you are and anything you want to pursue I support. You know, those kinds of conversations. Resiliency is the confidence in your own ability to recover from adversity. And that's really hard to develop if you're afraid of failure.
Dr. Sutton: (51:01)
This is all really great and I'm really looking forward to the books. I think this is such an important subject and it definitely sounds like it will be really helpful to parents, and it's a great addition. I mean, you're having this impact with the schools, and now making that available to parents and now these books sound like really great resources to really kind of help families get those tools. Having to wait to get the professional help when sometimes they can't get the profession help.
Dr. Khanna: (51:33)
Right. And our website actually does have some links to how to find help in their communities and through different organizations. So we definitely know that there is a time when it is important to get help. When kids are struggling you need support beyond what you can offer at home, and so we do have resources for that as well that we're linking to and other organizations. So I really do hope we're reaching people and it's so exciting that there are these technologies that allow us to do that through websites, through blogs, through social media and through podcasts like you're doing. I think it's wonderful.
Dr. Sutton: (52:22)
Well, thank you so much for taking the time today and I really appreciate it.
Dr. Khanna: (52:26)
Thank you so much for having me. It's been fun and an honor, and I look forward to hearing some of your other podcasts.
Dr. Sutton: (52:39)
Well, thank you, take care.
Dr. Sutton: (52:39)
If you're wanting to use this podcast to earn 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 feedback, and 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, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to therapy on the cutting edge 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 interviewing Dr. Muniya Khanna, a psychologist researcher, teacher, and author. Muniya is a specialist in childhood anxiety, and has been involved in a number of research studies on treatment using cognitive behavioral therapy, also in research on pediatric OCD. She has worked with Dr. Phil Kendall to create a computerized version of his Coping Cat program that is used with children, with anxiety in schools, and many other contexts. She's a founder and director of the OCD and Anxiety Institute in Pennsylvania, and is a research scientist at Children's Hospital in Philadelphia. She's also in the process of publishing her second book, which will be on resiliency. Let's listen.
So the interview. Welcome Muniya. Thanks for joining us today.
Dr. Khanna: (01:21)
Thanks so much for having me.
Dr. Sutton: (01:23)
So I've known you for some years now. I actually did a training many years ago with an exposure with response prevention for OCD. And then was given your name as a consultant for working with kids with OCD and pediatric anxiety. And you've been my kind of go-to person over the years to talk about difficult cases and such. Also you were involved with developing Coping Cat, the program for kids and the computerized CBT program and lots of other stuff.
Dr. Khanna: (01:57)
Yeah I can kind of walk you through the background. Maybe even before we had originally met, so I started out, I was so lucky, you know, I think just sometimes the universe sort of leads you in the right direction. And it did, for me, I met Marty Seligman as an undergrad and actually that was, my first research internship or externship, what you'll call that. And it really just changed everything for me. I was a pre-med, sort of heading in that field. I knew I wanted to help people, but this was really life changing for me.
We learned that the study I was a part of was the study where they were testing out CBT, brief CBT in schools. And they were comparing schools with this brief CBT against schools that were not getting this CBT. These were short groups, you know, 35 minute groups. And I think over the course of eight to 16 weeks, we were seeing huge changes in how often the kids would meet criteria for depression, not just at the end of the groups, but even long-term compared to the other schools that never received those groups. And it was for me just the amount of impact that words were having, words that were offered that were relatively low cost in a sense of for public schools. Certainly to be able to offer something, and in just eight weeks or 12 weeks or 16 weeks, depending on the program that they were seeing such change, long-term change; changes in the way kids were functioning globally, not just with depression ratings.
And that was it for me. I said to myself, you know, everybody should know about this. And then after meeting Marty Seligman and his great team, Karen Reivich and Andrew Shantay at Penn, I was, again, lucky to be able to work with Phil Kendall. Phil was the author of the Coping Cat treatment. And the Coping Cat was the, what is now the standard of best practice for psychotherapy in children with anxiety. It's a 16 session CBT program. Phil was my graduate mentor. I learned my work in anxiety in kids. I learned everything from Phil and his team at temple. And then Phil and I became collaborators and friends in that graduate school process. And I said to him, I think you know, this was now 2001, 2000. And I said, Phil, technology is going to be big in mental health and it's such a great way to reach kids. And it's such a great way to reach families and maybe even help standardize some of the quality of care being offered. And maybe a way to reduce the friction between, you know, we talk so much about how to bridge the gap between research, world data, and community world data, right. We know that kids are getting treatment, even the ones who are getting treatment in the community are not getting evidence-based treatments. And so we're not seeing the same outcomes.
Dr. Khanna: (06:10)
So first, the problem is that there's not enough people getting treatment. The next problem is that those who are, are not getting the kind of care that is leading to any real measurable change and how to bridge that gap. And for me, technology was a clear direction to go for psychotherapy. And at that time, there wasn't you know, iPhones there were not really iPhones. There were no smart phones. There were flip phones and of course the internet was still, it was there, but it was not what it is today, you know? So I had some background, my father's a technologist actually, in his way, had sort of started that path early. And so I learned from him young and became very sort of computer comfortable. I'll say, I'm not an expert, you know, a coder or anything like that, but I'll say that I became very comfortable with technology early on. And so it was a really easy fit for me and Phil, being really progressive and supportive and excited by the prospect. We wrote our first program together, Camp Cope-A-Lot. Camp Cope-A-Lot is a 12 session online, now it was on a DVD at the time, but now, it doesn't work anymore because the flash doesn't work, but everything is now online, cloud-based and still very much alive. And you know, it's a quick fast forward, but schools are calling me daily to implement Camp Cope-A-Lot for their remote support system.
Dr. Sutton: (08:16)
Yeah, everything with COVID right now. So it's online, that's good to know.
Dr. Khanna: (08:21)
It's online, you know, copingcatparents.com is still the hub of where we're keeping all of our programs and, you know, again, very grateful that it was there, that we had this program ready to go when COVID hit, and we had data to support it. And so very excited that we're sharing this with school districts and with families, families are able to buy it too, so parents can buy the programs. Anyway, so that was 2002 when we wrote Camp Cope-A-Lot. And we launched it, it became a research study that we did. I finished in 2008 after that, again, very lucky to start working with Marty Franklin and John Piacentini in the OCD world. So Marty Franklin gave me my first job after my internship, or actually it was my post-doc at Columbia where Marty came to visit me and offered me my first role as a faculty member at the University of Pennsylvania. And so, so exciting, it was a dream job. I had gone to Penn as an undergrad and sort of came full circle back, and Edna Foa was there. And so I was really lucky again, to be able to learn PE from Edna, learn about exposure and response prevention from Edna and from Marty, and Marty is such a brilliant clinician. I just fell in love with the work, the EXRP work.
Dr. Sutton: (10:08)
EXRP being the prolonged exposure, then exposure, response, prevention?
Dr. Khanna: (10:13)
Correct. So EXRP exposure with response prevention, that's the treatment that we've found to be most effective for OCD. And Marty is just so brilliant in really using that approach with kids. And that's where we did our work. He had already started this work called the Pots trials. It was the pediatric OCD treatment study. And so they had done the first randomized trial evaluating CBT with exposure and response prevention compared to medication, which was an SSRI, compared to the combination of both, versus placebo. It was a multi-site trial, the first to be done in kids. And he had published that. And Gemma and I came on board when the second trial was being started. And then I stayed on to evaluate and develop the work on Junior OCD treatment, which then we started calling that Pots Jr. And really what that was, was working with kids between the ages of five and eight, and translating the same approach, but for a younger population, and that involved parents a lot more. And so I stayed and we published the results of those trials while I was there. And it was such exciting and fulfilling work to be able to see these treatments that I could see for years working in session, that we could show now that, you know, we have the data to say, yes, actually it's working and it's working as good as medications in many cases. And it's, you know, maybe even longer term better to do treatment with CBT than without CBT for longer-term impact. So that was so rewarding.
Dr. Sutton: (12:34)
Doing exposure with response prevention with CBT? Okay, combining those two, as well as-how did it do with and without the medication?
Dr. Khanna: (12:43)
Yeah, so the results were that medication alone was as effective as CBT with exposure alone. So either one alone was effective. But when you combine them, it was more effective. And when you looked longer term, out to a year, that it seemed that CBT was having longer term impact, and that, you know, I'll say this, not through data, but through what we've, what we've come to understand is that after about a year, some changes might need to happen on the medication side. And so we don't have the post one year data on that. I think that will be coming too, but, um, but basically it was, you know, the punchline was that if you haven't already started medication, that perhaps CBT with exposure and response prevention would be the one to try if you had a child with OCD, because that is a low side effect you know, long-term impact potential to be all they need to benefit and to come to, you know, a level of symptom severity that was not significantly interfering in their lives. So again, so fulfilling for us to say, yep this is working, these are words, these are things we can share with low negative side effects. And the difficult part of course about therapy is that you have to find someone who knows how to provide it, and you have to have the time to be able to participate in it, and you have to have the resources to be able to pay for it, or insurance that will be able to cover it. And all of those things are tremendous barriers through mass scale. And we've seen that bridge that I talked about earlier is still very much a wide gap. And that sort of takes me to where I am now. I think that's what brought me to where the work is today, which is really just to disseminate this in more, more ways and more delivery methods, and simplify as much as possible, so that maybe paraprofessionals can also be as effective as highly trained professionals to support kids on the front lines a bit more.
Dr. Sutton: (15:40)
Tell me more about that, what kind of things are you doing?
Dr. Khanna: (15:43)
So I'll say first, I'll sort of categorize it. So if I say as a whole my job, you know, my career focus has shifted really from where I was trying to be part of the team that was evaluating and making sure these treatments were working, making sure we have the data to support it, making sure, you know, this is what we wanted to recommend. And now that we've sort of gotten to that point where yes, you know, we know a few things, we know there are things that can help now; the job has kind of shifted to how do we get these tools into the hands of families who need it? And so now, if I say that that is sort of my umbrella focus, I've kind of taken it in a few different directions. One is in writing much more. I'm trying to do a lot more direct to consumer writing as opposed to research writing, you know, which is where things were in the previous 20 years of my life. And then moving that to, you know, I've been writing, of course the first book was called the Worry Workbook, which is a workbook designed for kids to learn and use some of these strategies to help them manage stress and worry. And it's designed really for parents to work with their children and that the workbook is sort of something that walks them through the steps. And so that was a first pass of writing to consumers directly. And that book now is being used in some school districts as well, which is wonderful. So again, more tools out to the public.
Dr. Khanna: (17:35)
The other book that you mentioned is the Resilience Recipe and Phil Kendall, and I are authors on the Resilience Recipe. It'll be coming out in November. And what we really wanted to do is, again, speak directly to the parents, you know, that again I'll back up a little bit, in the time that we were doing that research and the time that we are in today, the sense of urgency has multiplied so greatly. You know, I don't even know how to wrap my head around it really. The numbers of kids who are struggling, obviously, you know, we've seen the news of the doubling rates of suicide in kids under 24. We've seen the trajectory of anxiety and depression and the COVID pandemic has now taken those numbers and sort of blown them out of the water. I don't have the numbers exactly to give you right now, they're being collected, but I think what we can say except is that I'm sure that they're extraordinary. And I think that the need for action, and the need for people, you know, to become empowered themselves is so important. And I got very frustrated, Phil and I both got frustrated because what was happening was we were speaking to other researchers, we were, I mean, it was great. We were talking with schools and hospitals and clinics. And so places that had staffed, you know, experts and clinicians, they were using Coping Cat and they were using the exposure and response prevention. So that was wonderful. That was a great big step for the first round of things. But, you know, this round has to be so much more active and so much more in the hands of everyone. And the frustration was that partially it was our fault. We're here not really talking to the public. We're not really on TV. You don't see that many expert clinical psychologists on social media or on television or radio. I think you are then getting people who are maybe interpreting the work, or maybe talking about their own life experience, or maybe that they've heard, they've become sort of students of this enough that they're now communicating and being effective communicators have reached audiences. And when we can hear that, yes, they're saying some things that are definitely good, they're definitely leaving out a lot of things that need to be included. And so I felt sort of personally responsible. And so Phil and I...you know Coping Cat has been given to the people, it's in the hands of the people who we wanted it to get to; in the hospitals and the clinics, but now we really need to get this to the hands of parents.
Dr. Khanna: (21:03)
And so the resilience recipe is really using the components of cognitive behavioral therapy for kids, with anxiety and depression, and combining it really to be, David Barlow would use the term, trans diagnostic. Not really just for kids with anxiety, not really just for kids with depression, but using the principles that have worked for those populations to make those principles available to parents, and make the strategies practical and something that you can do at home. And something that I'm hoping that parents can feel empowered by, because then they can handle a lot of these conversations. In fact, that's one of the end of every chapter has key takeaways, but throughout there's conversation starters, because it's designed to help that conversation. You know, what do I say to...so a top 10 list on a blog is only so effective if I know how to present it or how to even make sense of it. How do I know when to use it? How do I know if that even applies to my child? So what we've tried to do is make it clear where those top 10 tips came from in terms of here's the principles behind them. And then here's how you would talk about it. And here's just even an example of a conversation starter.
Dr. Sutton: (22:40)
Yeah. Kind of like the principal driven kind of trans diagnostic approach, that's being able to cover numerous issues. And when the parents have the principles, then they can kind of maybe have a little more confidence or a little more ease in discussing that and having conversations with kids rather than just kind of going off the information itself and not really understanding kind of the principle it comes from.
Dr. Khanna: (23:04)
That's exactly right. Because I, again, I really tried to avoid a list of top 10 tips when I wrote this, because I really wanted to make it really understood and then be able to create a lifestyle around it, not just sort of a short-term fix of a problem, you know?
Dr. Sutton: (23:30)
Well, that's pretty true about the idea of resilience. So that's always been a great interest of mine because one of my specialties is around teenagers and there's all these different things that we can do to help them through their childhood, through their life. But I always wonder, in my own experience and others that I've known that have gone through difficult things and come through and been able to go on to be successful and other people that struggle and don't, and really kind of have a hard time in life. Yeah. I mean, how is it...it's really kind of hard to figure out what leads that person to overcome those obstacles and go on to thrive, while others get really kind of stuck. And particularly too, even now that I have my own children, really looking at how do I help influence their values and giving them tools and so on. But also having that kind of resiliency and overcoming obstacles that might come in their lifetime or so on. So yeah, I'd love to hear your thoughts on just kind of resiliency and I know, Marty Seligman, and kind of where some of your work was starting was a lot of positive psychology resiliency. I would love to hear your thoughts on those.
Dr. Khanna: (24:40)
Yeah. And definitely influenced by Marty Seligman, Karen Reivich and Andrew Shantay's work on resiliency. But I'll say that what we might do a little bit differently, or maybe not differently, but maybe in addition to some of the principles that they speak to, we really incorporate a lot of the principles about anxiety that we understand, we understand the stress, that fight or flight cycle very well. And, and it's very core to a lot of our coping strategies, meaning that when somebody is anxious, that your response is not just because of the situation you're in, you know. I have a challenge, I have a test, or I have, you know, let's say I'm worried about getting COVID--the circumstances there. And a lot of times we really, we just assume that that circumstance is creating that stress, but what we understand of anxiety and the source of all of our anxieties is that our body is so pre-programmed to scan for danger and to over-interpret danger, just in protection. You know, we call it the caveman brain for kids, or the bully as John Marsh would have put it. We use that language, I think a lot more than maybe we did with the resiliency work when we were working with kids that were more prone to the more depressive response to stress. So what we did was really married the two being that they are really similar in so many ways, even though they might be manifesting in different ways. But that's sort of a digression I'll say, is that my take on resilience is that, this is very much the crux of the book that's coming out. So I'll sort of just try to give you the bullets. Our theory about what it takes to develop resiliency in kids is an approach that really combines four key concepts.
Dr. Khanna: (27:16)
And those, so I'll just take one at a time. The first is the need for a development of awareness and of compassion. So awareness and compassion is one of our first main blocks. You know, the main foundation of being resilient is to have a great amount of awareness of your own physical response, your self-talk, or your inner voice response, your tendencies in terms of behaviors and where that comes from. The insight, and that understanding is such a powerful tool in being able to counteract, it gives you the opportunity to observe. And then that observation gives you the distance between the feeling that may have come instinctively and what to do next. And so the first key component I think to help is the need to help them build that awareness.
Dr. Sutton: (28:27)
Mindfulness that kind of, detective kind of look at what's going on, that's kind of leading to those emotions or behaviors or such.
Dr. Khanna: (28:36)
Yes. Right. And we do, we use the same kind of cognitive behavioral strategies like the detective or listening to your inner voice or listening to your self talk. So we use some of those and it all fits in that same category of mindfulness, of being able to really slow down and become more aware. And that, like I said, it's such a powerful tool in giving us control over what happens next. You know, we want to be in creation of what happens next, as opposed to just being responding to whatever situation we're in. And that's true for when things go badly or when things are challenging, you know? So that's resilience again, it's a sort of a universal strategy for both types of challenges, both anxiety provoking, and those that are about loss and grief and loneliness.
Dr. Sutton: (29:42)
It is kind of like moving from being reactive to being responsive, rather than just reacting to something kind of deciding how do I want to respond to this situation?
Dr. Khanna: (29:51)
Exactly. And so we teach the worry cycle, you've seen me draw that cycle so many times, in workshops and, with kids, that drawing is just a map. It helps you sort of start mapping and that map gives you then a visual and now something actionable, something that you can get a distance from enough to do something about. So, that's sort of the first key component. We'll talk about it in the book.
Dr. Sutton: (30:22)
The compassion part. Can you speak to that? Is that like the coping thoughts?
Dr. Khanna: (30:28)
No, not yet. Actually, I think the compassion part is about observing them without judgment, as we sometimes feel, because I'm anxious, I'm weak, you know, because I reacted badly, it was an error, it was me being just too vulnerable. I'm not this enough. I'm not that enough. I need to be...
Dr. Sutton: (30:51)
Non-judgmental. You know, noticing rather than judging.
Dr. Khanna: (30:54)
Yes. Noticing rather than judging. And, and I spend a lot of time talking about perfectionism actually. I'll say that, I think that's one of the biggest challenges even though, of course, COVID and sort of the uncertainty of our future is going to trump all of this for a little while. But I think a lot of what our kids were struggling with was just this perfectionism culture. You know, this culture of you will have a good life only if you, and then all of these conditions. If you are hardworking enough, smart enough, thin enough, funny enough, have enough friends. So then our kids are getting into this checklist of how am I doing on all of these things. And as you know, our brain will never help us out in that area. And also just life is usually, you know, of course I'm mediocre compared to a million other people. So if I really start measuring this out, it's always gonna turn out not great and easy for the mind to start heading in that direction of I'm not good enough.
So I think the idea of giving parents the language to...we have to be a filter almost to that message, the fact that you are seeing messages and hearing messages in school and online and on shows about what it takes to be happy. I think those conversations have to be had early and often. It's not that we are going to change society by saying ignore all of those things, put away your phone. That's not how it's gonna work. It has to be through conversations, you know, conversations about what makes you worthy has nothing to do with any of those things, and sort of the meaninglessness of the things that we say we've kind of started to say are meaningful. And so we want them to have that space to be compassionate about failure because you can't really approach and be resilient and bounce back from failure when everybody around you is saying failure is not okay. So we're sort of expecting kids to just, you know, Hey, you've got these SATs that I have told you since the fifth grade that are the benchmark or the gateway to the rest of your life, but don't worry about it. You shouldn't stress about that, you should be resilient. And how can we get more grit, you know, can we get you more gritty now? And I think it's really unfair if we're not having the conversations to take apart your intelligence is not measured by this test. I know, you know your worth, your value in society is not measured by this test. Where you go to, what sweatshirt you put on is not the sign of what I think of you. And if anybody does that, it's their loss or their shortcoming of thinking through this more, you know? And so, not to over-simplify, but again, the conversation about this, communicating our values as opposed to our fears is something, I think we reiterate a few times in the book, when it comes to helping build compassion.
Dr. Khanna: (34:27)
Okay, so then the second part. So the second part, and this is where those coping thoughts come in, this is about cultivating a mindset of growth and flexibility. That's where we spend a lot of time as a major next component required to build resilience. We want to help them see how their thoughts and their behaviors are influencing how they feel, and that it's not just, again what they're experiencing in the world, and having a mindset that there is no such thing as failure, because I'm never gonna stop trying. One opportunity ends or closes, another will come, I will pursue another. And that rejection is a learning opportunity. It's a temporary delay of what comes next, or it's just a part of the path to what comes next, opportunities to learn and grow. And the fact that I talk about it as having a superpower. You know, the fact that we have the ability to reflect is kind of our biggest, it's our kryptonite. We reflect and we think of all the things we did wrong. We think of all the things we could have avoided, and then start planning how to avoid them in the future. So in a lot of ways, we think our mind is just always doing the wrong thing and just sort of a pain, but actually it's our superpower. It's actually the thing that helps us the most, we're surviving because we get to innovate and problem solve and learn and grow and change and love and give and share. And so we talk about how to really build up that focus, the focus on the creating and the doing and the learning, as opposed to the reflection of what didn't go well. And that's where we talk about coping thoughts and thinking, deciding which thought is the one that is actually the most useful as you move forward.
Dr. Sutton: (36:40)
Okay. That kind of awareness, compassion, and how did you phrase the second one again?
Dr. Khanna: (36:46)
Cultivating a mindset of growth and flexibility.
Dr. Sutton: (36:51)
Like growth mindset.
Dr. Khanna: (36:53)
A growth mindset. Of course, Carol Dweck absolutely has influenced this. And the work in flexibility, you know, influenced by many as well, Ana (inaudible), Marty Franklin, and many others, that when we become too rigid about exactly what we expect and exactly what we should do, it puts us at risk of again, being too focused on what didn't happen, as opposed to growth. And then this one is the big one, I'll say for us in the anxiety world, is the third one, which is adopting a lifestyle of approach. So in our research, and as you know, we call this exposure. Exposure is such a terrible word. It sounds like something you wouldn't want. But what I like to call it, approach more than exposure, I actually think approach might be more accurate.
Dr. Sutton: (38:01)
We're trying to do the opposite of avoidance, which means approaching.
Dr. Khanna: (38:06)
Yes. And an openness to that approach. So this is where I think a lot of clinicians, even though they are well studied in a lot of this, I think a lot of times, even good clinicians really hold back from doing this real push towards approach in the context of therapy. And I think we do this at home too, meaning as parents, I think, you know, Eli Leibowitz, who's done some incredible work at the Yale Child Study Center has just recently done a study on, his work has shown that parents in therapy learning, how to not accommodate or learning how to encourage approach is as effective as having a child in therapy. So that's how powerful first, how powerful a parent's role is. Second, how powerful that shift from avoidance to approach is when it comes to building resilience and building that. We always say, I just wish they were more confident. I wish they could handle stress more. And this lifestyle of approach is something that we spend a lot of time talking about. So it's not just making sure they pet the dog, if they're afraid of the dog. It's also just sort of saying, I don't know who's going to be there, but let's go anyway. I don't know who's going to be at camp. Maybe you're going to be horrible at baseball. I don't know, but let's just sign up anyway.
Dr. Sutton: (39:59)
But I'd love to hear that research too, because I don't know if you know, but I do a lot of family work. One of my main focus is working with family systems, particularly that piece.
Dr. Khanna: (40:09)
Yeah. And his work is fantastic. And he has some great books that I wish I had the, the references to give you right away. But what I'll say is if you google Eli Liebowitz, or look him up on Amazon, his books are terrific. And really spend a lot of time talking about how families can encourage approach. And he might say reduce accommodation.
Dr. Sutton: (40:36)
As families are trying to help out, sometimes they're reinforcing avoidance. So it's not out of malice or anything, they're just trying to help them.
Dr. Khanna: (40:45)
Not at all. And a lot of times we're just trying to keep them functional. I tell my parents all the time that I get it, he didn't want to go out of the car to get to the, you know, baseball, let's use that as the example, and you need to get to your daughter's, you know, doctor's appointment and you can't sit there. So, okay. Let's just skip baseball tonight. We got to go to the doctor's appointment, or you got to sort of push things along, or your stomach is feeling sick, but I have to go to work. Okay. Why don't you just stay home today? And it goes from zero to 90, very quickly in terms of becoming interfering. And that's usually when we'll hear that things are a problem, but it's not just that parents are sort of...I think it's unfair to label all of it as helicopter parenting or overprotection. I don't think it's all that, I think sometimes we respond to our kids. Some kids who are already sort of in approach mindset already, if you let them skip a day of school because their stomach hurts because they're nervous for a test, that's not necessarily going to translate into a lifetime of stress and test anxiety. And so a lot of times we're just sort of, we're playing it by ear, we're reading their response. And we're kind of trying to figure out, where do I draw the line? And sometimes it's just harder to know. And sometimes our kids are asking for things in a way that sounds very reasonable, but is actually not the right way to go. And again, that's why I think understanding the principles really helps because it helps you kind of navigate, how do I know? Is this the time I have to hold the line? Or can I let this one go. She doesn't want to go on that sleep over, is she anxious about sleeping away from me, or at home? Or is it that she's not particularly fond of this group of friends that is going to be there and is that kind of okay, or is it social anxiety, and so you want to now understand a little bit about what the decision-making can look like. And I think that's, again, understanding the principles of avoidance and the function of avoidance. It can help you kind of map out, is this just a one-time thing, certain group of kids, maybe this is fine, you don't have to go. Or do I see, oh, this is a pattern of every time there's a group of kids that they're not as comfortable with that they choose to not go. Maybe I should encourage more of this. You know, maybe we should try more of this. Maybe I should push a little more. So really building that lifestyle of approach is such an important thing. And certainly if you know that they're avoiding something specific, we also talk through how to really push on those more specific things. So if there is something like test anxiety, or if there is something like social anxiety or a lot of anxiety around new social experiences, we do also discuss how to support kids and practicing that in step-by-step, as we would in an exposure world, we would say do it slowly in small steps. So it's manageable to move to the next step. So we do talk about that, but I think we also talk about it more generally, too, in terms of this approach lifestyle.
Dr. Khanna: (44:21)
And then the last one is kind of an easy kind of quick one, which is not easy to implement or easy to summarize, is that our job is as parents, we aren't teaching something. We aren't, we are teaching, but we are not. Let's say, we, by doing and saying any of these things, we are not the change agents. You know, we are just guides. We are supports. And that's really the thing we can do most that's where our power is. I think most valuable is how to give compassion, how to give support, how to appreciate, our kids don't hear enough. I think about what we appreciate about them, and again, to no fault of anyone, it's not that we're a particularly harsh society that way, it's just other than saying, 'I love you, have a great day.' Things get busy and we keep moving and it's hard to say, 'oh my God, that was really funny. You know, you cracked me up, that was really funny,' more often than, 'oh, good job that you did so well, you're a really good math student,' you know? And so of course both should be appreciated, but just generally coming at, I like to have a five to one ratio of saying things that are positive, noticing things that are positive. And then that makes your one thing that you would say, 'Hey, you know, why don't you try this?' or, 'Hey, you know, it seems like you're having a hard time with this, maybe we could do something to help.' That one correction or that one teaching moment can become more powerful because you're not, you know, you haven't become part of the anxiety cycle, then you're part of the security piece, right? You're aware things go to feel good. And that is, I think so powerful. So, you know, we've labeled that section, the ultimate gift of security, and it's not really security in that oh, you can make sure that you're never in a car accident, I wish we could do that. But security and knowing that you're always there and that there's nothing they can say or do that would change how much you believe in them, how much you value them, how much you of course love them. And then again, over and over in as many ways as you can, to a five to one ratio, and I would say in the COVID time, when we're seeing maybe more irritability, maybe more withdrawal, maybe a little bit more of regression, even, Not a little bit, I mean, in some cases, a lot of regression, of having been isolated for so long and having routines be off for so long, it's making everyone, including adults, really lose center and feel a lot of angst and feel a lot of agitation and making all of us a little bit too irritable. In this world, I would say double that, you know, make it a 10 to 1 ratio rather than saying, I need to discipline more because they're just acting out and this is not okay in my house. I would say support, guide, encourage, tell them their impact, tell them they're valued and meet them where they are. Play a video game, even though you're worried about too much screen time with them, invite their kids, have their friends on a zoom call so that they can have that friend contact. But even if it's more than usual or seems like not much, right now I don't think there can be too much love.
Dr. Sutton: (48:30)
I think, too, that's the proactive part of parenting that sometimes is more effortful to kind of shift our attention in that direction. Sometimes we get more into the reactive parenting and just kind of taking stuff away or stop doing that, or don't do that rather than, you know, having to reinforce like, oh, you're doing that really well. We're trying to get that to happen more. I think about it too, that kind of makes me think when you're talking about this, as parents, as guidance support that, you know, I always think about one of the greatest gifts that parents can give to their kids is their faith in them, even though maybe they had a tough time at school, like they know they're going to make it through this, they're going to do all right. Or even though maybe this happened or that happened, they can see that in them that they're going to make it through all these things that kind of really can instill that kind of resiliency to not you know, like every kind of bump in the road or kind of wave is going to be the end of it. Typically I do a lot of work with kids and families with ADHD and adults with ADHD and shifting to that, you know, oftentimes kids with ADHD that mentioned that five to one, they get in so much more trouble and they end up-we really have to increase that by a lot more. And really the goal often times with kids with ADHD is just been to get them through their childhood without a great deal of shame. Building that resiliency, because that's one of the things parents and adults with ADHD struggle with.
Dr. Khanna: (50:02)
One hundred percent agreed. I could not, I would underline that a million times. Absolutely. And I think you put it so well, you know, making it through childhood, that their childhood should be an experience of unconditional love. And that feeling of course, again, we're approaching challenges where we're encouraging approach. So it's not that we're saying, you know, we're not anything we're not challenging, we're not growing. We pursue all of those things. But with the understanding that we believe in you, you don't have to fit the mold of everything else, everybody else, that you are enough exactly as you are and anything you want to pursue I support. You know, those kinds of conversations. Resiliency is the confidence in your own ability to recover from adversity. And that's really hard to develop if you're afraid of failure.
Dr. Sutton: (51:01)
This is all really great and I'm really looking forward to the books. I think this is such an important subject and it definitely sounds like it will be really helpful to parents, and it's a great addition. I mean, you're having this impact with the schools, and now making that available to parents and now these books sound like really great resources to really kind of help families get those tools. Having to wait to get the professional help when sometimes they can't get the profession help.
Dr. Khanna: (51:33)
Right. And our website actually does have some links to how to find help in their communities and through different organizations. So we definitely know that there is a time when it is important to get help. When kids are struggling you need support beyond what you can offer at home, and so we do have resources for that as well that we're linking to and other organizations. So I really do hope we're reaching people and it's so exciting that there are these technologies that allow us to do that through websites, through blogs, through social media and through podcasts like you're doing. I think it's wonderful.
Dr. Sutton: (52:22)
Well, thank you so much for taking the time today and I really appreciate it.
Dr. Khanna: (52:26)
Thank you so much for having me. It's been fun and an honor, and I look forward to hearing some of your other podcasts.
Dr. Sutton: (52:39)
Well, thank you, take care.
Dr. Sutton: (52:39)
If you're wanting to use this podcast to earn 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 feedback, and 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, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.