Podcast: Dr. Kathryn Boger on Teens and Anxiety

Our thoughts and perceptions can shape how we react to situations. Before today’s interview, our trusty host talks about attempting to move past a bout of severe depression.

Trevor then sits down with Dr. Kathryn Boger, program director of the McLean Anxiety Mastery Program (8:45), who shares her thoughts on ways to retrain our brains to realize things are not as bad as we initially think.

Dr. Boger also discusses child and adolescent mental health, particularly the importance of early detection and early invention in children and adolescents, while also sharing what it was like for her to grow up as an anxious child.

Check out Dr. Boger’s TEDx talk about child and adolescent mental health!

Episode Transcript

Trevor: Here we are first episode of 2019. Welcome new listeners, welcome returning listeners. Fifth episode, not bad. This opener might be a bit of a bummer, and I apologize for that. I’m feeling the decline. I am descending. The darkness is kind of closing in a bit. It’s kind of a cliché, but life moves in waves. Well, so does depression. You’ve got good periods, and you’ve got bad periods, and when you’ve done this enough, you recognize when the bad period is coming on. I’m definitely entering one right now, be it because of the January months and the cold weather here in New England. It’s very cold today. The fact that my apartment issue still isn’t resolved, I still haven’t found a place. I went and looked at a couple places this weekend and no-go on that. Also, a good friend is still sitting my cat for me. That was only supposed to be a couple weeks, and here we are going on almost two months. Everything that I’ve talked to all of you about in these intros, the exercises that I use in order for me to stay mindful and to manage my mental illness, they are failing me.

This happens. Those of us who have to manage our mental illnesses know that sometimes it’s a losing battle, and you just got to move forward, and you got to get through it. You know, every time somebody tells me, “Oh, you just need to move forward,” my eyes just roll so far into the back of my head. The fact of the matter is that it’s true. That’s all I can do. That’s all I’ve got. I don’t have any mindfulness exercise that I can talk about. I don’t have a new approach. I’m using the same approaches every day, letting the emotions slide off, doing a mindfulness exercise, you know? Counting colors and shapes, and I’m doing all those things, and it’s just not working. Instead I just want to go to bed, and that’s it. All day. I just want to go to sleep.

It’s funny. Yesterday I went to go see a foreign film, Japanese film called “Shoplifters,” which is playing in a few cities across the country. It was very good, but I was positive that within five minutes I was just going to fall asleep during it. Not because I expected it to be bad. So many people told me it was great, and it really indeed was great. It was a great movie. I forced myself to go and just kind of accepted that I was probably going to fall asleep. I made it through, but today at work and most days, in general, I’m just tired. No matter how much sleep I get, no matter if I take a melatonin, it doesn’t matter. I’m exhausted, and that is depression. I can feel it setting in. I can see the tunnel vision coming on. I had a staff meeting today. I was very quiet during it, haven’t been very social. I’m going to go see a movie with a friend tonight, and that friend’s not very talkative, so it works out well for me. I really don’t have much to say.

That’s it. That’s all I’ve got is to keep moving forward, and I know that’s the only way, and it irritates me and frustrates me to no end that that is the only way, that there isn’t another way. I’d like a new approach, I’d like just something different, but nope. Just keep moving forward. So yeah, sorry, I’m kind of a downer today. That’s going to happen. I decided when I was going to record these intros and outros that I wouldn’t try to cover up how I’m feeling, and I am not feeling well at all today. I feel the pressure in my head, I feel the pressure in my eyes, sometimes I just think I’m gonna to start crying for no reason. It’s real and again, just move forward. It sucks, oh my God, it sucks. I know some of you out there get it. You’re kind of nodding, and you’re like, “Oh yeah, I was there just yesterday. I’m there right now.”

I know some of you get it, and it’s all you can do is just try and put one foot in front of the other and just keep going. We’ll see. I mean, not “We’ll see,” that’s really negative. I know I will come out of it. I always do come out of it, but there’s always this fear, no matter how many times it happens, there’s this fear, and I feel it. I feel it in my body. All over there’s this fear, “Am I going to make it out this time?” Depression is such an intense feeling, it really is, and no matter how many times I experience it, I’ll never stop wondering if this is going to be the one that drags me all the way down to the point where I’m not going to be able to get out of it. Yeah, fun times.

On that note, today’s episode I interviewed Dr. Kathryn Boger, who works here at McLean Hospital, and she is board certified in clinical child and adolescent psychology by the American Board of Professional Psychology, and she specializes in cognitive behavioral therapy, CBT for anxiety, mood and substance use disorders. Dr. Boger helped to develop and is currently the program director for the McLean Anxiety Mastery Program, and her and I have a really good talk about anxiety in adolescents. She knows her stuff, and I really enjoy talking to her.

No, dude. No worries. It’s all good.

Colleague: I didn’t realize you were filming.

Trevor: No, no, no, the last file didn’t record, so I had to come back in here and rerecord it, and I should have told you.

Colleague: All right. Cool.

Trevor: Sorry, I didn’t mean to give you the look of Satan, it just came out.

Colleague: I would have given myself—

Trevor: I’m sorry, dude.

Colleague: No, I would’ve looked ... don’t worry about it. I’m sorry.

Trevor: No, no worries.

Did you hear that? There was no excuse for what I just did. A coworker just came into the studio. They forgot their bag, and I just shot that person a pretty rough thousand-yard stare. Yeah, could you hear the tension? You know, I know it kind of went silent, but oh, my gosh. That wasn’t good. So yeah, Dr. Boger and I, we had a really good talk, and she really knows her stuff, so this is me interviewing Dr. Kathryn Boger. Hope you enjoy.

Trevor: You had a lot of anxiety leading up to this.

Kathryn: Are we recording? Just curious.

Trevor: Of course we’re recording.

Kathryn: Oh, okay. I didn’t know if this was on or not. I was certainly nervous about this because I’ve never done a podcast before, so I didn’t know what to expect.

Trevor: Did you think you were coming in here, and I was going to grill you or come at you or anything like that?

Kathryn: I think it’s more a question of just that anticipatory anxiety of what if you ask a question I can’t answer? What if my mind goes blank? Then usually once we get into it then the anxiety dissipates, and it’s actually enjoyable.

Trevor: Is that something that, let’s go back to your childhood, specifically school. Is that something that would bother you when you were called upon and you didn’t know what the answer was?

Kathryn: It’s funny that you say that. Growing up, I wasn’t particularly an anxious kid, and, at the same time, I was really shy about raising my hand in class. I remember in fifth grade my teacher pulling me aside and saying, “Hey, you have a lot of great things to say. Why don’t you take a chance? So when you have an idea, just raise your hand. We’ll start out when you really think you know the answer you can raise your hand and then eventually over time take some chances, even when you think you might not know the answer.” That actually really helped. I still remember it. It was fifth grade, and, looking back, that’s actually a form of exposure therapy. That’s what we’re doing with kids is having them essentially retrain their brains by putting themselves in the situation and seeing that it’s really not as bad as they think, or, if it’s bad, they can handle it.

Trevor: Okay, so you said, “This is what we do with kids.” Explain what you’re doing here with kids here at McLean.

Kathryn: Sure. So, I am the program director for what’s called the McLean Anxiety Mastery Program. It’s a program for children and adolescents aged seven to 19 who have anxiety and OCD. It’s a relatively new program. We started it about five years ago with the goal of helping these kids get their lives back on track more quickly. Many of our kids are, because of their anxiety, because of their OCD, they’re either not attending school, or, if they are, they’re not accessing their education. They’re not doing the things they love, like their extracurriculars. They’re not socializing, and so we thought, “Let’s provide evidence-based care in the form of cognitive behavioral therapy on a really intensive basis.” So, four afternoons a week for at least a month, with the goal of helping them bring those things that the anxiety has sort of knocked offline back online. We’re trying to get these kids on a path more quickly.

Trevor: You yourself don’t struggle with anxiety, the level of anxiety that is treated here. You at least empathize, it sounds like from what you went through younger, you at least empathize and sympathize with these kids. The feeling to have all the attention on you and to maybe even know the answer but just be crippled by being put on the spot and having to just talk. You said you got over that through natural exposure therapy in school, but a lot of these kids have not.

Kathryn: Yeah, sometimes it’s the opposite. A teacher might say, “Okay it looks like you’re having a hard time answering questions in class. Let’s give you a break on that. You can take a pause. You don’t have to raise your hand.” Then you have learning sort of in the other direction, or you’re robbed of the opportunity to actually try. Yeah, I think that empathy piece is crucial. We often talk to parents about, you know, parents, in particular, who don’t have anxiety who have children who have anxiety. Sometimes that can be really hard to know just how unbelievably painful and debilitating it can be. We’ll try to have them identify a moment in their lives when they felt the most terrified or scared, the moment when they lost their kid in the library or the moment when they gave a speech to 200 people, and they forgot everything they were going to say. Then have them think about repeating the feelings that they’re experiencing in their body, the thoughts they’re having in their mind over and over and over again, all day long, all night long, with no escape day after day and try to get those parents in the mindset of this is what your child’s reality is like.

This is not something that’s going away. You might have experienced this really upsetting moment for, you know, five, 10 minutes in time, and this is your child’s 24/7 life.

Trevor: I had a brief struggle with anxiety when I first started therapy about 20 years ago. A lot of what I’m dealing with now was certainly, not certainly, I don’t really know, I’m assuming passed down biologically. I don’t know—

Kathryn: Mm-hmm—

Trevor: That’s what I tell myself to sleep at night, you know?

Kathryn: Yeah—

Trevor: The anxiety was definitely learned behavior. Definitely.

Kathryn: Mm-hmm, yep.

Trevor: Is that what you’re finding with a lot of these kids? That anxious kids usually means anxious parents?

Kathryn: The research does show that if parents have anxiety, children and adolescents are significantly more likely to be anxious themselves.

Trevor: Is there a number?

Kathryn: Seven times more likely.

Trevor: Okay.

Kathryn: If a parent has an anxiety disorder. That said, we don’t know what exactly, how exactly, that translates. There’s multiple factors. There’s the biology piece, there’s temperament, there’s the child-rearing practices, there’s the environment—

Trevor: Go into the child-rearing practices. Explain the effect.

Kathryn: The caveat before I even start is that we’re certainly not in this business to blame anyone, and it’s never anyone’s fault, and I think, I talk to parents all the time about the fact that parenting an anxious child is unbelievably challenging, and a lot of other parents will say to the parents of our anxious kids, “Oh why don’t you just do this? Why don’t you try this? This worked for my child.” Parenting a child with anxiety is very counterintuitive. What can often happen is this process where let’s say you have a child whose temperament is more behaviorally inhibited, a child who’s shying away from new things, new experiences and that child then pulls for a different type of parenting.

If that child is afraid of, let’s say dogs, and you’re walking down the street with that child, the child is probably going to cling to you when they see that dog, and so you’re probably going to scoop up and hold and “protect” your child, but, over time, what can develop is this overprotective and kind of overcontrolling dynamic where the child is not getting the opportunity to face hardship, to face those challenges. That’s actually how you would want to manage the anxiety, right? Is to continually put yourself in the challenging situations.

Trevor: What about a child who has anxiety over bullying because they’re being bullied every day? Exposing them to bullies is not going to help the matter any.

Kathryn: Yes, and I think that’s a good distinction. There are times when the anxiety actually fits the situation. What we’re looking at are situations where kids tend to catastrophize so their minds are jumping to the worst case scenario or overgeneralize, thinking that these horrible things are so much more likely to happen. There are certainly times when scary things or bad things happen, and that’s a normal reaction to those things.

Trevor: Okay, but what about kids that came from the worst-case scenario? I mean, I’m sure without going into specifics you’ve treated some kids that you’re like, you know, inside your mind you’re like, “How is this person still alive?”

Kathryn: Yeah, and I think it’s really interesting because you can see two different people who experienced the same life experiences, horrible things, and they might have different outcomes, partly because of the vulnerabilities that they bring to the table, the temperament, the biology piece, and I think one thing that we’ve learned from being in this business is how unbelievably resilient children can be, too. I think that’s sometimes something that we don’t actually appreciate enough.

Trevor: Mm-hmm, so this program, did you help start it? How did this program come to be?

Kathryn: Two colleagues and I about five years ago were working on a residential unit, and we were seeing kids whom we would treat intensively on this residential unit and then we would try to step them down to outpatient services in the community and really struggled.

Trevor: Explain “Step them down.”

Kathryn: Sure, so these would be kids who would be on a 24/7 residential unit. The idea would be then, would be to transition them back to home.

Trevor: Okay.

Kathryn: And some outpatient services, so this would be sort of once a week, and we would be looking for evidence-based treatment and with anxiety and depression that’s going to be cognitive behavioral therapy, and we really struggled to find solid cognitive behavioral therapists or even just cognitive behavioral therapists for children and adolescents in the area—

Trevor: Why?

Kathryn: It is a great question. I think it’s a failure of our system. Oftentimes the resources that are available are not insurance-based and they’re pretty costly too. That becomes prohibitive for families, but the hope, I mean, part of our goal in starting this program is to train future generations of clinicians who can do this work and go out in the community and serve more kids.

Trevor: Silly question, but do you think it’s also a New England thing?

Kathryn: No, I actually think in terms of this country we’re lucky to be where we are. That actually there are more evidence-based therapy opportunities here than there are in a lot of parts of this country.

Trevor: See, I find that funny because a lot of the country, and I think those of us that live in New England will even admit that we’re some of the most emotionally maladjusted people in the country and yet the most well-respected mental health hospital is right here in Massachusetts. In the country. There’s proof to that claim, but you’re saying we don’t have the CBT resources for what we need here.

Kathryn: Yes, and at the same time we have probably more resources than many places in the country. In fact, when we started this program, it was meant to be, I mean, it’s an outpatient program, and so we thought we would draw locally, and then we started to find that we were getting kids from all over the state and then all over the country and actually now even all over the world. Even though it’s an outpatient program, we have families who will relocate for a month=plus and stay in a hotel in order to get their child that evidence-based intensive treatment because it just doesn’t exist.

Trevor: How much does social media play into all of this? Before you answer that, I want to say that while I see social media as a very strong influence, I also believe that it’s become a quick scapegoat in the national dialogue. “Well, it’s social media. It’s social media. It’s social media.”

Kathryn: Right.

Trevor: Okay, I get how social media has created a paradigm for kids where I was bullied in school but when I got home I wasn’t bullied by that kid anymore, okay? Now, with social media, you’re bullied 24/7. There’s no escape.

Kathryn: Right.

Trevor: I also have found that it’s become a scapegoat, and people don’t want to address that there are more factors, or factors that might be closer to home, than an Instagram profile.

Kathryn: Yeah, I mean I think the short answer is we don’t know. I see social media as a double-edged sword. There are actually times when we harness social media in the exposure work that we do. For example, a child who’s very socially anxious and avoidant, we’re helping them actually reach out to peers via texting or the phone or calling or Facebook, and it’s actually a way to start connecting. At the same time, what you don’t want to do with that child is then have them avoid that real life in-person interaction because they can hide behind a device. I think something that we are seeing, and time will tell in terms of the role it plays, is that kids are not getting that downtime for their brains. What we might call “white space.” I recently heard someone reference it being called “white space” in a talk. This idea that, you know, back in the day you might actually just come home from school, finish your homework, and then just have time for your brain to be bored and just to be.

Trevor: Oh, come on. Stop. There was a comedian who’s justifiably under fire right now, but there’s a comedian who talks something like that cell phones and social media have taken away that feeling of what it’s like to sit in a waiting room and be bored.

Kathryn: Yep.

Trevor: Okay, sitting in a waiting room bored sucks, and I find it to be a complete, complete waste of time, and it does nothing for me—

Kathryn: What you don’t realize, now I’m cutting you off, sorry.

Trevor: No, good.

Kathryn: That’s a form of exposure. You are sitting in your own skin, you are tolerating whatever thoughts, whatever feelings come up, and that’s actually really important in terms of your own learning and your own, sort of, brain retraining. We work with many kids who actually cannot sit in their own skin. The second they’re not being entertained by something they go into a panic mode. This idea that you can sit for one minute, two minutes and feel the feelings in your body, feel the emotions you’re having, experience those thoughts, that’s actually really important, and it’s a life skill.

Trevor: Yeah, but the problem with that is we have this new generation of kids where we are subjecting them to ... their minds can’t rest because there’s so much input coming to them from every direction. That is not their fault.

Kathryn: Mm-hmm—

Trevor: That is not their fault.

Kathryn: Yeah, no one’s blaming the kids for this, right.

Trevor: Oh, I think a lot of people are blaming the kids for this. I mean, how many times have I heard, “Oh, this new generation is the most useless generation, the most self-absorbed generation.” I mean, it’s just not fair.

Kathryn: Then you go to the playground or the grocery store, and you look at the parent-child dynamic, and 90% of the parents are not interacting with their kids. They’re looking down, getting texting neck because they’re on their phones. I don’t know that it’s just one generation.

Trevor: Don’t knock texting neck, okay? Everybody suffers from it.

Kathryn: I think I have it too.

Trevor: I certainly have it, but I don’t have kids. It’s just a problem I’m going to have to deal with on my own. Okay, well, do you see progress?

Kathryn: With regard to social media or with regard to—

Trevor: To kids?

Kathryn: We see unbelievable amounts of progress. Of course it varies depending on level of severity and motivation, willingness at the outset of treatment and throughout, and for kids who were able to really hook into treatment to have that motivation and willingness, it’s really unbelievable to see what they’re able to do. I think at this age, their brains are so plastic, and the hope is that you’re rewriting the course of their entire lives, and it’s been really neat. We’ve had some kids who, for example, have been homebound for months or even years because of their anxiety who figure out step by step, it’s not overnight, but step by step how to reclaim their lives and really manage that anxiety so that they can function in this world.

Now, because we’ve been in existence for a little while, some of them are going off to college and really standing on their own two feet, which has been really gratifying for us to see.

Trevor: I mean, you’ve told me that there are situations where parents bring their children to the program, and the child, it doesn’t even have to do with the program, they have anxiety of just getting out of the car. Period. It doesn’t matter where they are.

Kathryn: Oh yeah, absolutely. For some of our kids, we will call it “car therapy,” and we will meet them at the car. We’ll get in the car, and sometimes that’s for one session, trying to coax them out of the car, get them into our clinic. Sometimes it’s a week or two because, again, these kids, their worlds have narrowed so much that they’re absolutely terrified to be in new settings, to meet new people, and so before we can even think about doing exposure work, a true exposure is just taking the first step out of the car.

Trevor: Why can’t I get that kind of service to my car, but like, food? Like I can get food delivered to my house, but sometimes I just get in my car, and I’m like, “No, I’m hungry now.”

Kathryn: I know.

Trevor: I just want it to come here, and I don’t care how I look eating my dinner in my car. I’m hungry now. I’ve got an hour of traffic to sit in on the way home. Let’s just do this.

Kathryn: That should be the new business model, “We’ll meet you in the car, and we’ll bring you a Big Mac”—

Trevor: You can subsidize the program by also delivering food.

Kathryn: That would be really nice. Well, it is nice because part of what we do with exposure work is we try to get the kids, to the degree possible, out of the office into the community. We’re taking them to real-life settings. We’re going to stores and restaurants, and they’re ordering food and eating out in public. There is sort of that natural incentive or reward because all of a sudden they’re able to do these things that they feel like “normal kids” are doing or that they used to do before the anxiety took over. We get to be there with them enjoying the food and enjoying the experience.

Trevor: Hmm. Is this where you want to be? You want to be with this program?

Kathryn: Yes, I mean, I think this is what I’ve always wanted to do is work with this population, specifically children, adolescents who have anxiety and mood problems. I think we know that anxiety is the most common psychiatric disorder in children and adolescents, but it’s also the most treatable, and it’s remarkable, again, to see what kids and adolescents are able to do if you get them the right tools. Our plan next is to expand the services that we’re providing so that we are really offering a true continuum of care where we can help families because unfortunately there’s such a great demand we have a pretty significant wait list. We want to be able to help families who are waiting, just sitting, waiting on our wait list prepare for a program like ours.

Helping the parents by providing parent guidance, helping the children by providing some sort of basic foundational CBT skills. Then we want to treat them intensively and then step them down to the once-a-week traditional CBT, and we are going into schools and educating folks who are on the ground working with these children every day.

Trevor: When the doctor says CBT, we mean cognitive behavioral therapy. Can you give me just a quick rundown of that?

Kathryn: Sure. It’s the idea that our thoughts and our behaviors are affecting our feelings. We call that the three-component model.

Trevor: Oh, I know. I know—

Kathryn: You know all about that—

Trevor: I was a patient here twice, so I know. Jeez—

Kathryn: So you’ve been there, done that—

Trevor: Oh, my gosh, yes. Burned into my brain.

Kathryn: Good, so you could probably describe it better than I could.

Trevor: See I talk about it in my sleep.

Kathryn: Two of the biggest components are sort of the cognitive piece, and what we’re trying to do with the cognitive piece is help folks identify their thinking patterns and then introduce more flexibility in their thinking. It often feels that the thoughts we have are fact. If I’m thinking right now that this interview is going poorly then that’s just a fact.

Trevor: Do you think it’s going poorly?

Kathryn: I hope not. That’s why I said, “If.” What we’re trying to teach these kids is our thoughts are just interpretations of reality—

Trevor: Did you see how excited I got when you were like, “Do you think it’s going—” I was like, “Okay here we go—”

Kathryn: “Now we’re getting to the good stuff.”—

Trevor: “Now we’re getting to the good stuff.” I’m sorry, keep going.

Kathryn: The idea that our thoughts are not fact and that it’s really just opinions and in any given situation there are multiple ways to think about something, which then affects how we feel and how we behave. Number one, introducing flexibility in our thinking. Learning how to challenge some of those unhelpful thoughts. Number two, we know that where there’s anxiety there’s avoidance. We call that sort of a best friend relationship. We want to break up that relationship between anxiety and avoidance because in the short term avoidance gives you relief, you feel better. “Ugh I didn’t go to school” or “I didn’t give that big presentation. I feel so much better in the moment.” In the long term, we know that that just reinforces anxiety and makes it grow.

What we’re trying to do with exposure work is expose children in a really gradual, planful manner to the things that they’re most afraid of so that we can retrain their brains to see that it’s really not as bad as they think, or, if it is bad, they can manage it.

Trevor: Is there ever a case where avoidance actually is the answer?

Kathryn: Well, I think if there’s something that actually in reality is truly dangerous. We’re not going to expose a kid to a snake that would actually bite the person or a truly dangerous situation.

Trevor: Obviously, but—

Kathryn: Yeah.

Trevor: Have you ever had a kid that it’s just, it’s so ingrained in them that maybe avoidance of this one thing might be best? Or by enabling that does that just disregard the program entirely? Do you have to not give up on that exposure therapy? You’ve got to just keep hammering away at it? It sounds like that ultimately has to be the case.

Kathryn: I think what it comes down to is the person’s own values and goals, so what really matters to that person? It might be that for a given person they have this fear, so they have a fear of spiders, but they’re never around spiders. It doesn’t really affect their day-to-day life. They don’t care. We’re not going to waste our time focusing on exposure work to spiders. We’re trying to figure out what really matters to this child and to the family and then expose them to the things that actually make a meaningful life.

Trevor: I’m going to give you a scenario. What if you’re dealing with a female child in their teens whose anxiety is almost exclusively wrapped up in men. Men scare ... then you find out from their past that they have good reason—

Kathryn: Mm-hmm—

Trevor: You know? Let’s not go into details, but we can all imagine. They have good reason to be terrified by men. Not just one man but maybe a series of men. Fathers, boyfriends, relatives, friends, whatever, have continually let them down in the worst way. What do you do?

Kathryn: That’s where a really comprehensive and thorough evaluation at the outset comes into play, and so you would evaluate the child, and if you see that there is some type of trauma history particularly related to men then we would be thinking of switching gears and actually doing a different form of evidence-based therapy first. What I would be looking at there is probably trauma-focused CBT. If there were a true trauma situation with associated symptoms, try to stabilize that trauma and then figure out what are the remaining symptoms and what needs to be targeted here.

Trevor: How did somebody who had anxiety about talking in class when they were young come to be a part of creating a very influential program? I personally have witnessed the program. It’s pretty amazing. I mean, what was the journey?

Kathryn: I think from a young age I knew that I wanted to be in this field helping in some way with children and adolescents. Then believe it or not the journey actually started at McLean because the summer between my junior and senior year in college I actually worked as a mental health staff member on one of the units. I just came alive. I loved the work. We, at the time, we were creating a behavioral activation group for children and adolescents, or really adolescents actually, which basically means exercise to improve mood and help with anxiety. I think what was really exciting for me at the time is here were all these kids who had been struggling for years, and at that point these kids would be in the unit for months at a time, to try to figure out what were their strengths? What kind of brought them to life? What would motivate them to start working on their challenges to me was the most exciting.

I can remember there was one kid who had never exercised before in his life. He kind of begrudgingly joined our fitness behavioral activation group, and he was wearing big boots. Not the kind of boots you would go for a run in or exercise in, but eventually, over time, we got him to go on small jogs with us and then go for runs, and for a long time he’d be running in these huge boots, which were totally inappropriate for that activity. Then eventually we were able to get him some secondhand sneakers and to see this kid kind of come to life and be so proud of himself when he hit different markers, like being able to run that first mile, learning how to stretch and take care of his body and to feel like he was able to take steps to improve his mood and to kind of have more ownership over his life, that to me was so, so exciting.

I then majored in psychology in college, went off to Stanford, worked in a lab in the mood and anxiety lab for two years and then came back and did clinical psych graduate school. I found over time that I kept gravitating back to that anxiety and mood work and work with children and adolescents.

Trevor: Why did you keep gravitating towards it?

Kathryn: For me, there’s so much hope for this population. This idea that if you can work with children who are really young, again, you’re really retraining their brain, rewiring their brains, and you can change the entire course of their lives. I think that is just absolutely so exciting. I think the big challenge is figuring out for a kid who’s stuck, what is it that makes this kid tick and how do we get this child to be willing to take some initial steps? How do you hook them into treatment? That’s the biggest challenge and I think the most exciting part.

Trevor: Your job day to day, exposure therapy, dealing with kids who struggle from anxiety. What, and you don’t have to go into detail, but what personal experiences have you had with mental illness. Not specifically, doesn’t have to be you, but with a loved one or a friend or a family member and how does, dealing with that, how does that differ from doing your job every day?

Kathryn: I think one example was that, and when I give this example I’m not trying to say that this is as hard as someone’s experience who has, for example, generalized anxiety disorder or panic disorder or something kind of more debilitating, but I did, growing up, have a huge fear of mice and decided as I was in graduate school and venturing into this world of CBT and exposure therapy that if I was going to ask kids to start facing their fears and to do that tough work that I actually should walk the walk myself. I actually started to engage in exposure therapy around my fear of mice—

Trevor: Oh come on—

Kathryn: Which doesn’t sound like a big deal, and at the same time I think it was a really humbling experience —

Trevor: I’m sorry. I’m not invalidating you because I would be like, “No, I’m just going to just be afraid of mice. I’m fine with this.”

Kathryn: Well, you’d be surprised though in how many settings there are mice. At the time I was working in a hospital setting, and there were mice everywhere to the point where a mouse ran across the floor of a session. They’re there. In doing this exposure therapy, again, it was a really humbling experience because this is this one circumscribed fear. On the surface doesn’t seem like a big deal, but I eventually got to the point where I would go to pet stores, have a mouse in my hand and be absolutely terrified to the core, potentially in tears. One time I got bitten by the mouse, and I remember thinking, “Oh my gosh, I’m asking seven year olds to do this. This is so much harder than I ever thought,” and so I do think that helps with the empathy piece of just having some experience of being so terrified that you want to just jump out of your skin and to know how hard it is to face that.

Keeping in mind in a program like ours these are not adults who willingly go into treatment. Oftentimes it’s the parents who decide, “This is a problem for my child. I’m going to bring my child into this program,” and so then we’re asking this child who would probably rather be doing anything but this to face his or her fears every day.

Trevor: When the mouse bit you, were you just like, “What the hell am I doing? What is this?”

Kathryn: It was really not fun. I will tell ... for me or for the people around me.

Trevor: For you specifically.

Kathryn: I don’t know. I think I made a bit of a scene. Yeah, but the good thing is that was my worst-case scenario fear, and I lived it and I survived, which is actually what you want with these. Particularly with natural exposures, it’s really one of the benefits is that things happen, like the mouse bites you or you go to do a social exposure and somebody in the community is not that nice, and you have to learn how to manage that.

Trevor: I’m going to talk about something that you have in your office that really made me upset. We talked about this the other day. The reason I got upset was for, I want the listeners to know, it was completely unreasonable why I was upset. There’s this little sign in your office that says, “Get comfortable being uncomfortable,” and I hate it, but I do know that it’s right. I do know that it’s correct, but sometimes, and I know it’s not just me, sometimes the uncomfortable is so unbearable that why would I ever want to become comfortable with this ever?

Kathryn: Well, I think what oftentimes happens with anxiety is that people are having these adversive symptoms. So adversive physical symptoms, thoughts, and all they want to do is get away from them and understandably so—

Trevor: Absolutely.

Kathryn: Right? It makes sense. We’re all human, we want to protect ourselves, we’re going to avoid what feels really bad.

Trevor: Absolutely.

Kathryn: Unfortunately, what can happen is that in people’s efforts to avoid those physical symptoms they inadvertently make the problem that much worse. For example, if I start to experience panic symptoms every time I go to into my school library, so I start to avoid the school library. Well, what I’m doing is I’m training my brain that, “I can’t do this. I can’t handle it. This is scary. This is bad.” Then my world starts to narrow, and I’m losing opportunities for learning, for engaging with other people, and then all of a sudden these things that really matter to me are starting to go offline in my life. I think the idea is that teaching people, and certainly the sign is an oversimplification, I get that.

Trevor: You’re damn right it’s an oversimplification.

Kathryn: The idea is not to invalidate just how challenging it is to sit with uncomfortable feelings and that is really the heart of what exposure work is in the service of having a more meaningful and full life of the things that matter.

Trevor: Give me an example of some. Do you do mindfulness exercises with the kids?

Kathryn: Yes.

Trevor: Okay, give me one or two mindfulness exercises.

Kathryn: One example of a mindfulness exercise that a lot of the children like is mindful eating. For example, you’ll have them eat a raisin or an M&M, just one, and it’s as if it’s the first raisin or M&M that that child has ever had in his or her life.

Trevor: That’s a good one.

Kathryn: They’re using all their senses. Feeling the texture of it, smelling it, noticing what it feels like in their hands and then in their mouth and then really getting the sensations. Oftentimes kids will say, “I never had such an experience with M&Ms before. Oftentimes I just throw my hand in the bag, and I’m not so aware of each sensation.”

Another thing that we teach them is mindful walking. Again, we’ll take them out into nature, or to the degree possible in Cambridge, nature and have them use all of their senses. Smell and touch and taste and sound, sight, to really plug into their surroundings and be truly present in a way that they often aren’t in their lives. I think for kids sometimes that more active mindfulness activity is an easier way to start versus the sort of sitting meditation mindfulness.

Trevor: Let’s say we have a parent of a child suffering from anxiety, or we actually maybe just have a child with anxiety listening to this podcast right now. What is the one thing they need to know to get started on this process of not just getting into this program but getting over anxiety.

Kathryn: It’s hard to pick one thing because there are a lot of things that come to mind. I think for the children and adolescents having them just understand that relationship between anxiety and avoidance and having them understand that while in the short term they get relief, in the longer term it’s actually making the anxiety bigger. That oftentimes what can start as one fear then will grow into multiple fears as the person starts to pull back and avoid. What we’re not asking the child to do is dive in the deep end and start facing their biggest fears but maybe stick a pinky toe in the water and sort of test it out and slowly start to face things that are more challenging.

I think for the parents what we’re often asking parents to do is shift their attention so when your child is really struggling with anxiety, your whole family likely is held captive. You’re all in crisis mode, and so much attention and energy is put on that anxiety and the avoidance. Unfortunately though, that can actually reinforce anxiety and avoidance, and so what we’re asking families to do is over time is shift that attention and put the attention on brave behavior, on approached behavior and remove it from the anxiety and avoidance. Essentially starve the anxiety and avoidance because we know how reinforcing attention is. Easier said than done.

Trevor: Yeah?

Kathryn: Well, essentially what we’re asking parents in our program to do is to step back when their children are struggling and that, as a parent myself, it goes against every parenting instinct is to want to reach in and protect and help your child not experience that distress, and what we know is that for children to actually move through this and learn how to mange their anxiety, parents have to take a step back, and they have to tolerate their children struggling. Sometimes we will have children struggling, let’s say having a full-blown panic attack and parents wanting to reach in and wanting to “fix,” and we will actually ask the parent to step back and to tolerate allowing the child to sort of ride it out on his or her own. Really, really tough.

Trevor: That sounds awful.

Kathryn: Yeah, I think it is awful, and when parents over time start to see that this actually works and they start to gain more confidence in their child’s ability to stand on their own two feet, that’s where the real progress starts to happen.

Trevor: So, you yourself with your own children have had to, I guess any parent would have to do this, you’ve had to ride it out when you’ve kind of wanted to intervene. You’ve had to sit back?

Kathryn: Yeah, and I think, again, there’s another place where it’s really humbling to be a clinician and a human being and a parent because you realize that the things you ask other people to do are actually that much more challenging when you’re doing them yourself. Small things like sitting down with your child and having your child do homework, and your child is making a bunch of mistakes, and to sit back and to let them make those mistakes and not want to reach in and correct or fix. Or not want to win the first argument that they have with a child at school, call the other mom and try to “fix” the problem but to step back and let your child manage. It’s really, really hard, and I’ve seen it in enough situations, and I know from the research that the stepping back is actually what allows children to gain mastery and confidence.

Trevor: What about the opposite? I don’t know if anxiety and confidence are linked but what about those kids that, I don’t know if they could benefit from a little anxiety but maybe benefit from a moment of pause before jumping into something?

Kathryn: Yep. I think that’s where mindfulness certainly can come in. There are plenty of children. I think what you’re describing—

Trevor: Do you see kids that, I’m sorry to cut you off, but do you see kids that impulsively do something even if it’s something that they don’t want to do because it’s, “I’ve got to do something. I can’t just sit here and languish and wait for all my opportunities to go away. I’ve got to jump in and do something.”

Kathryn: Yes—

Trevor: “Even if it’s not thought out.”

Kathryn: Sure, sure, because when you’re experiencing a heightened emotion, anxiety or depression or anger, you’re going to be as you know probably well, in emotion mind. So you’re not thinking with a rational part of your brain. What we see with anxiety, or kids whose anxiety manifests as fight, flight, freeze. In fight mode, kids can often be aggressive, they can lash out, yell at people. On the surface it looks like they’re being obstinate or defiant. On the inside, it’s like they’re sort of a caged animal. They’re terrified, and that’s just how they manage is to lash out.

Then you see kids whose anxiety manifests as flight. Sometimes this is just sort of avoiding certain activities or tasks. Other times we’ve actually had kids who would literally run. They would all of a sudden start to experience anxiety and could not tolerate sitting in their own skin and so, they would sprint. That’s certainly a challenge as a treatment provider to manage that one.

Then you have the kids who then freeze mode where it’s like they’re stuck in the mud. Their anxiety is so strong that they just dig their heels in and get pretty rigid. Again, that’s also challenging to work with because on the outside it can look like a kid is being challenging or difficult, where on the inside they’re really just feeling incredibly overwhelmed and stuck.

Trevor: Okay, so give me some success stories.

Kathryn: I can do this in a de-identified way. I’ll speak broadly—

Trevor: That’s what I was expecting, absolutely.

Kathryn: Okay, so I can think of children who’ve come into the program when I said before that anxiety can manifest in fight, flight, freeze. In fight mode, so children who would scream and yell and refuse to come in the clinic—

Trevor: Hit? Kick?

Kathryn: Oh, hit, kick, swear. We’ve seen it all. It took a lot of work, and I think a lot of it stemmed from mistrust of clinicians and providers and what this whole process would be, and so much of it is earning their trust and making that connection, and I’m so proud of our team because I think it’s a group of wonderful, really bright but also just wonderful human beings who work so hard to get to know these kids and to figure out, again, what makes them tick. How do we in a very individualized way help each one of these children? Some of these stories you see these kids who, again, come in in extreme distress, angry, not wanting to be there slowly over time as you kind of hook them into treatment get them to start facing their fears. We have seen kids who change the entire course of their lives, and they have gone from being completely school avoidant to being back in the classroom, engaging with their friends, engaging in the activity that they love. Then it becomes sort of an upward spiral from there because then every single day they’re having experiences that then reinforce that approach behavior versus the avoidance.

That’s just one of many examples. I think something else that we’ve seen a lot are kids whose fear starts as one sort of circumscribed thing. So, for example, we see a ton of emetophobia, which is fear of vomit. Doesn’t sound like it would be a big deal but oftentimes—

Trevor: It sounds to me like it would be a big deal, yeah.

Kathryn: It can really take over a child’s life. So you start with a fear of vomit, and the more you’re afraid of going into settings where people are going to vomit you start to have panic attacks in those settings, so then you pull back from those settings, and you develop agoraphobia, and so the more you’re avoiding your life then you start to develop depression and potentially social anxiety because now you’re not practicing engaging with peers. All of a sudden your world has completely narrowed. We’re helping them first sort of learn to tolerate that fear of vomit and then tackle all of those other areas so that they feel like they are in the driver’s seat of their lives again.

Trevor: How long do you think we’ve gone?

Kathryn: I have no idea.

Trevor: Take a guess.

Kathryn: An hour?

Trevor: We’ve gone an hour.

Kathryn: Oh.

Trevor: This from the person who is deathly afraid of—

Kathryn: I wouldn’t say deathly afraid but—

Trevor: —of talking—

Kathryn: It was an exposure for me. It was my first-ever podcast—

Trevor: I was blowing it a bit out of proportion to create a little sense of drama, you know? A little exposure therapy for you. Is there anything you want to add?

Kathryn: I think the only thing I’d want to add is just that hope element. That, again, it’s remarkable to see what these children and adolescents are capable of if we as adults step back and let them do it. What we’re often talking about with our parents, even as young as age six, having parents step back a bit and think about different types of responsibility and tasks that kids can start to engage in just to have more control over their environments and more, sort of, mastery.

For example, a child at age six is feeding the dogs and putting away dishes every day. It sounds like a very small thing, but it’s a step in this larger trajectory of parents continually stepping back and showing their love by indicating to their kids that they can handle things to the point where when a child is now 18 or 19, the child knows how to schedule his or her own appointments, can do his or her own assignments, really feels like he’s in control or she’s in control of his or her life.

Trevor: Last question—do you see a gender disparity when it comes to anxiety?

Kathryn: The numbers tend to be relatively equal when children are young, but then when you get into pre and adolescents, then all of a sudden we’re seeing increasing rates in girls.

Trevor: Why?

Kathryn: Again, there’s not one specific answer to that question. It’s a variety of factors.

Trevor: Does body politics play into a lot of it?

Kathryn: Sure and society and sort of cultural values. All of those pieces certainly can play in, but we don’t yet have one specific answer. In our program, we’ve actually seen pretty equal gender breakdown. I think the challenge is that with the boys that we see oftentimes there’s this shame element where—

Trevor: Oh yeah.

Kathryn: The boys feel that they’re “weak” if they express anxiety or any kind of vulnerability. That that’s not what it means to be a man. We’re trying to help them realize to sort of shift that and think about vulnerability as a form of strength. Not an easy concept for some of these kids to get and so important. We’re working with parents to model that and children to really try to embody that in their lives.

Trevor: Okay. That was good. Yeah?

Kathryn: Thanks. It was fun.

Trevor: You okay?

Kathryn: Yeah, no. It was not as scary as I thought. It was kind of enjoyable.

Trevor: You thought it was going to be scary?

Kathryn: Well, I just didn’t know what to expect, so, again—

Trevor: I work for McLean. No hit jobs here, you know? Okay. Well, thank you very much, Dr. Boger. I really appreciate it.

Kathryn: Thank you.

Trevor: Okay.

You know, for somebody that was nervous about doing the podcast, she sure didn’t sound it, didn’t she? Dr. Boger is a lot of fun. We had a really good time. I would like to interview her again in the future. Yeah, we had a good time. So, yeah, what did I say before moving forward? I’m still moving forward. Yes, after that interview I’m still doing it. Slowly inching, centimetering, is that a thing? I don’t know. Centimetering forward. Millimetering forward. I’m going forward. I’m trying. Oh, my gosh, I just want to go to sleep. All I want to do. Oh boy. We’ll be back in two weeks. Will we see you? I think we’ll see you. You’re coming back, right? Nod your head. It doesn’t matter if somebody in the car next to you thinks you’re crazy for you to be nodding your head to yourself. Just nod your head. “Yeah, I’m going to come back. I’m going to come back, Trev. I’m going to come back to Mindful Things.”

Cool, we’ll see you in two weeks.

Thank you for listening to Mindful Things, the official podcast of McLean Hospital. If you have any suggestions for special topics or future guests, please email us at @email, and don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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