Prologue

To begin, I am predisposed to treatments that are not specific to any one person’s style. Accordingly, I appreciate the fact that psychological therapies are no longer named for an individual (e.g., Rogerian therapy) but are instead labeled for the underlying principles (e.g., client-centered therapy). My approach to psychological therapy for youth can be labeled cognitive, behavioral, emotional, familial, and developmental: A mouthful. The approach is typically summarized as CBT (i.e., cognitive behavior therapy).

An introductory question: “Psychological therapy” or “psychotherapy?” The term “psychotherapy” has historical baggage (e.g., can refer to old-fashioned analysis). It’s not all negative baggage, but the baggage can be misleading. In contrast, the phrase “psychological treatment” is preferred because it does not have the baggage and because it more aptly captures what is being provided. For me, CBT is a psychological treatment that is more complex than its name.

In addition, psychological treatments, in my humble opinion (data driven as well), are better when they are forward-focused than when they try to look backward to unravel the past. Working and looking forward captures motivation and facilitates striving for and reaching goals. Looking backward provides room to wallow in the past, is unwittingly likely to foster blaming, and, importantly, is biased by widespread human recall errors. The past can’t be changed: the future is pliable.

The Narrative

My work, in both research and service provision, has largely focused on developing and evaluating psychological treatments for anxiety disorders in children and adolescents (hereafter referred to as youth). Maladaptive and interfering anxiety is the principal problem, but there are typically comorbidities (see Kendall et al., 2010 for data: see also Cummings et al., 2014; Frank et al., 2021; Peterman et al. , 2015a; Storch at al., 2022), and the anxiety is expressed somewhat differently at various points in development (see Drabick & Kendall, 2010; Kendall & Peterman, 2015). My approach holds that psychological treatment, as illustrated in my work with anxious youth, is superior when three key features direct the process: diagnostician, educator, and collaborator. And, importantly, when scientifically informed treatment is applied with flexibility.

Diagnostician

The word diagnostician typically elicits thoughts of DSM or ICD categorical systems. Although my work employs a diagnostic system, my use of the term here is different. I use “diagnostician” to refer to the need for the therapist to accurately match the mental health difficulties of the youth with the correct empirically informed treatment. In short, youth with internalizing disorders (e.g., anxiety; depression) and youth with externalizing disorders (e.g., conduct disorder) require different interventions. For example, in the context of a cognitive treatment goal, a wise therapist may guide anxious youth to not worry about unlikely consequences, but this approach would not be an informed treatment for youth with a conduct disorder. Regarding a behavioral treatment goal, added parental monitoring helps acting out youth, whereas less parental monitoring can facilitate gains for anxious youth. Being a diagnostician means gathering information from multiple sources that facilitates that the treatment accurately matches the problem.

Consider a parent who seeks services for anxiety because the child is shy and withdrawn. Following proper assessment, it appears that the parents’ perception of “anxious” was incorrect, albeit more socially acceptable to them than an accurate diagnosis of Autism Spectrum Disorder (ASD). Although difficult for the parents to accept, ASD was accurate and necessitated an appropriate ASD-focused intervention. A treatment for anxiety, no matter how effective for anxiety, may not be optimal for a youth with ASD. Consider a school counselor who refers a youth for anxiety treatment because, according to the referral, when the child gets anxious, he hits other kids, curses at teachers, and spits. An intervention for acting out, not for anxiety, would be the preferred approach. Each of these examples are meant to illustrate that the experience of anxiety can be present in a variety of youth, but for optimal outcomes the youth’s primary problem needs to be anxiety: matching the treatment to the nature of the disorder is the diagnostic.

Educator

A psychological therapist can be conceptualized as someone who teaches cognitive, emotional, and behavioral skills for adjustment. In the areas of cognition and behavior, for instance, there are data to explain the process by which learning and change takes place. For example, changing one’s self-talk (cognitive) has influence on emotional adjustment. Behaviors that are rewarded increase in the likelihood that they will occur more frequently. Although it does not need to be stated, there are no data to explain magic, other than the trick behind it. Sitting under triangles is not therapy. Therapy is not magic and not mystical—it’s a version of learning and change.

The relationship between the youth and therapist is important and a quality relationship facilitates learning. I suspect that many of us can recall an individual, whether it was a teacher or a coach, who was personable and kind, and whose influence was greater than they knew.

A great deal is learned by youth through observation of those that surround them. What they see and hear at home, from peers, and at school shapes how they interact with others and how they think about social relations, the future, and the world. Our youthful clients learn from our treatment content, but they also learn from what they observe. As therapists, we are a valuable model for reacting properly to situations and how best to process information. Along these lines, it is important to differentiate between a mastery model and a coping model.

Imagine that you observe a 12-year-old gymnast who is performing on a balance beam. The girl walks on the 4-inch-wide beam, then turns and completely flips, landing on the beam only to turn around and flip again. You are the observer. What do you say to yourself?

Likely, your self-talk includes something like “Whoa, I can’t do that.” I would go further and wager that, following your observation, your self-talk does not include “oh, that’s how you do it, let me try.” You are not likely, having watched a master, to want to give it a try. When you watch an expert, one’s internal dialogue tends to be dismissive. When an anxious child watches a therapist, if they are a mastery model, they may easily dismiss it. To help encourage the anxious individual, it is necessary for the therapist to be a coping model. A coping model displays an initial rection that is somewhat anxious, and then models a strategy to overcome the anxiety, then models a willingness to try, and then tries. Watching the gymnast as a coping model one could think out loud, “Wow, I can’t do that, but she has been trained, and I bet she’s practiced a lot. I haven’t been trained. I’m not ready to flip, but I can start by standing on the beam.” This verbal behavior can be followed by “Although I’m a novice, that’s something I could try. I’ll try standing on the beam for starters.” The observer gets to witness the reframing of the situation, the use of coping self-talk, and a willingness to give a first step a try. Serving as a coping model allows the youth to both see anxiety and that it can be managed. Not surprisingly, there are data to support the benefits of coping models over mastery models (Kazdin, 1974; Meichenbaum, 1971; see also Selzer et al. 2020).

Collaborator

A collaborative therapist works with youth. Specifically, for working with anxious youth, the therapist is the expert on anxiety, the client is the expert on the client, and both work together against unwanted anxiety. The anxiety is named (after March & Mulle, 1998) and the collaborative pair work together to teach each other how to manage the anxiety. Although several studies showed that differentially predicting outcomes were unsuccessful in identifying the “great” and the “lousy” features of therapists, it is fair to state that a therapist who is rated by blind observers of therapy session tapes as “collaborative” received higher youth ratings of the therapeutic alliance (Creed & Kendall, 2005). Similarly, Podell et al. (2013) reported that collaborative (compared to “teachy”) therapists had more favorable outcomes for 7–17-year-old clients.

One feature of being collaborative is the focus of “making sense of interactions”. In a dated approach, the therapist asks and hears what the client says about the past week and then tries to make sense of the client’s views of what transpired. The fact is, the client’s self-report is just that and, without verification of what actually took place, the therapist is on weak ground for challenging any false impressions. What is preferred, encouraged, and even central to the approach I endorse, is that the therapist and the client work together to unpack and make sense of the client’s recent and shared experiences. As a result, the therapist can then use the shared experience for any exercises to help the youth see things differently.

While collaborating, the focus of the therapy session is both present and future oriented. Little time is spent on retrospective reports and the analysis of past events. In addition to memory biases, the main reason for this is that one cannot go backwards and change what happened. However, one can move forward and try to do things differently, while instituting agency in what happens. Indeed, one feature of this approach is to anticipate the next likely developmental challenge and help the youth plan for and build skills around facing this upcoming challenge.

Implement Empirically Supported Programs with Flexibility

Imagine the following conversation between two mental health service providers. Person A and Person B are talking about a client, Jamie. Person A has a 14-year-old client who meets criteria for Generalized Anxiety Disorder (GAD). The client has had a prior episode of depression and has a variety of current complicating life circumstances including arguments with his parents. He and his family have limited financial resources.

Person A says, “I’ve worked with anxiety issues before, including GAD…and this guy sure has anxiety. He avoids school and worries about everything. He feels as though there is a catastrophe around every corner.”

Person B comments, “There’s this CBT program for anxiety that I read about, Coping cat. (Kendall & Hedtke, 2006a, 2006b: see also Beidas et al., 2010). It’s empirically supported, and there’s a version appropriate for Jamie’s age, the C.A.T. Project. (Kendall et al., 2002). I have heard good things.”

Person A replies, “Oh yeah, I’ve heard of it, and I have read a little bit about it. I hear it’s good stuff, but is it right for Jamie?”

But is it Right for Jamie?

What this question really means is, “does this individual case fit the general finding?” The question is critical, and it cuts across all kinds of clinical decision-making. Are mental health professionals any good at making such decisions? Are we good at thinking about when generally supported findings are applicable to individuals?

Early in the development of the science of clinical psychology, Paul Meehl discussed the conditions under which one should consider a case to be an exception to a general empirical finding (see also Dawes et al., 1989). Or, restating his question in my modern context “Is this empirically supported treatment right for my case?” “Does it fit for Jamie?”

How to best to go from a general finding to an individual case (see also ergodicity) is not an easy question. That said, there have been many studies of decision making and the findings of these studies warn that, like other people, we – the mental health service providers - are prone to make too many exceptions. In other words, when thinking about applying a program to a specific case, we are prone to think that the case, for whatever reason, is somehow justified as an exception. We are prone to think that the circumstances of our case support departing from the empirical findings. It is crucial that we need not fall prey to this cognitive processing error.

It is wise to consider race, ethnicity, comorbidity, culture, SES, life circumstances, gender identity, etc. when implementing an empirically supported treatment (EST) to ensure we can be flexible when working with various clients. Similarly, implementation can take place in various settings (e.g., schools, CMHCs, etc., see Kendall et al., 2023; Kendall et al., 2023). Research findings typically carry more information and more weight than the “features” of the individual that we mistakenly assume are sufficient to dictate the non-applicability of the treatment.

There is a superiority of actuarial (following the data) prediction over clinical (our thinking) prediction (see Meehl. 1957; Grove & Lloyd, 2006). There is strength in properly conducted treatment evaluations (i.e., randomized clinical trials; RCTs), and there is confidence that can be placed in the findings of these strong clinical studies. We need to admit that when we say the program “doesn’t fit for Jamie” we are guessing: our hunches are not empirically supported. We tend to place too much confidence in our subjective judgements, we assign them too much importance, and we tend to do so too frequently.

Thinking that we “know” why a treatment isn’t appropriate goes beyond the data: A more humble, and more accurate perspective is to suspect that a given feature of a client may be important and take it into account when implementing the empirically supported treatment program. Take the client’s specifics into account and apply the known-to-be-effective treatment with flexibility…flexibility within fidelity (Kendall, 2022; see also Rifkin et al., 2022).

What if you are using the Coping cat program and employ psychoeducation about anxiety and provide opportunities for exposure tasks, homework assignments, and rewards. You teach the client about self-talk, problem solving, and emotional understanding. The session on relaxation training was skipped because the youth had already been taught deep breathing and relaxation and demonstrated that he knew it. Did the treatment you provided have integrity? Was the treatment applied with flexibility?

In short, what are the components of treatment that are necessary to maintain fidelity and how can these known-to-be-effective programs be implemented with flexibility? Given this discussion is a personal reflection, let’s use the Coping cat program for anxious youth as an example.

As most of us know, anxiety disorders are the most common mental health problem for youth (present in nearly 20%; Racine et al., 2021). Youth anxiety disorders are associated with impairments in daily functioning (Peterman et al., 2015a; Rapee et al., in press), and typically persist into adulthood especially when they are associated with the onset of comorbid mental health disorders (Beesdo-Baum & Knappe, 2012; Swan & Kendall, 2016). CBT for youth anxiety is a well-established intervention, with meta-analyses concluding that approximately 60% of youth recover following treatment (Warwick et al., 2017). CBT for youth anxiety targets maladaptive anxious thinking to foster adaptive information processing, reduces anxious feelings, and enhances approach behavior (reduce avoidance) using rapport building, psychoeducation, cognitive restructuring, problem-solving, and exposure tasks. To illustrate flexibility within fidelity, let’s first overview these key components of youth anxiety treatments and then examine how they may be applied both flexibly and with fidelity.

Active Components of Youth Anxiety Treatments

There are treatment manuals that prescribe the delivery of an evidence-based intervention for youth anxiety. Although there is some variability among them, several key components are consistent across those programs with demonstrated efficacy.

Building Rapport

The therapeutic alliance (relationship; rapport; trust) has been positively, though modestly, associated with treatment outcomes for youth receiving treatment for anxiety (Cummings et al., 2013; Marker et al., 2013; Shirk & Karver, 2003). Meta-analytic work identified effect size estimates as 0.10 to 0.14. Rapport building can take numerous forms. Many youth find comfort easing into the therapeutic process by playing “get to know you” games, while older youth may prefer to simply chat. These practices can be extended throughout therapy by setting aside a few minutes at the end of a session to play a game (not necessarily therapy-related), or watch a YouTube video, with the goal that the client leaves the session feeling positive and connected. For youth in therapy, a distinct feature is that the decision to attend therapy is not solely made by the youth; rather, many youth present to therapy because of a caregiver’s desire for treatment. As such, as part of building rapport, it can be useful for therapists to inquire about the youth’s treatment concerns and validate any ambivalence or uncertainty. The main goal for the first session is for the child to come back for the second session. Collaborative therapists receive higher alliance scores (Creed & Kendall, 2005), and that increases the chances of the youth returning to the program.

Psychoeducation about Anxiety

Psychoeducation is considered a valuable component of CBT (Compton et al., 2004) and predicts better treatment outcomes (Chiappini et al., 2020). The function of psychoeducation is to increase the youth’s knowledge about anxiety including what anxiety feels/looks like, where it comes from, how it works, and dispelling myths about anxiety. In practice, therapists teach youth that anxiety is normal, and can even be helpful (e.g., alerting us when there is a real reason for concern), and then discuss ways in which anxiety that gets too high can become unhelpful (e.g., so stressed for a test you can’t focus and study). Anxiety is normal: we all experience it. However, anxiety can become problematic when one is overly sensitive and misinterprets the signals. One way to introduce this idea to youth is introducing the example of a fire alarm (or smoke detector). For instance, if you are in a large auditorium, and someone strikes a match and then blows it out, the whiff of smoke should not be enough to set off the fire alarm. If the fire alarm is too sensitive, it is triggered by the whiff of smoke and the sprinkler system kicks in and waters the entire room. In contrast, if the smoke detector isn’t sensitive enough, then a real fire, with flames ablaze, may not be enough to set off the fire alarm and there would be resulting damage to the building. Anxiety is like our body’s fire alarm (smoke detector). We want it to be sensitive and alert us when something is wrong, but not overly sensitive. This conversation allows the therapist to set expectations for treatment: the goal of therapy is not to eliminate anxiety but to have it be set at a reasonable sensitivity such that we can manage anxiety without letting it interfere.

To provide information about how anxiety works, the cognitive triangle (feeling, thoughts, behavior) is introduced, with particular emphasis on the connection between the emotion of anxiety and the physical symptoms that go with it. Activities can be used to identify the specific physical symptoms (e.g. signals/cues) that the youth experience. Younger children may enjoy tracing their body and drawing the manifestations of their physical symptoms (e.g., butterflies in the stomach; sweaty hands), while older youth may prefer to use a list of common symptoms to identify, which symptoms they feel, and at what levels of anxiety they begin to experience them (e.g., shaky hands, heart racing). In time, these symptoms/signals transform into helpful cues for thinking and acting differently.

Keep in mind that psychological treatments for youth need to follow a basic principle: Keep it simple! The smoke detector is but one example, and using a triangle is another. Although not all illustrations will be discussed, the principle nevertheless holds throughout treatment.

Cognitive Change

Consistent with the theory regarding the connection between thoughts and feelings, research on CBT for youth anxiety suggests that the cognitive restructuring component of treatment represents an active feature of change (Peris et al., 2015). A youth’s level of cognitive development is a factor that determines the relative utility of this component. Older youth may derive greater benefits from mastery of these skills, whereas the benefits may be less for children who have not yet developed meta-cognition (Waite et al., 2015). One way to address the connection between thoughts and feelings is negative self-talk. There are various ways to address self-talk (see also Latinjak et al., 2023): One way is to follow three steps: (1) Catch it, (2) Check it, (3) Change it. The ‘Catch it’ step refers to the identification of thoughts, particularly when anxious physical symptoms have been detected. Youth who have difficulty distinguishing thoughts from feelings may benefit from an exercise where they fill in thought bubbles above drawings of themselves or others in various anxiety-provoking situations. For younger children, it may be helpful to externalize the idea of thoughts, by identifying a character such as a “worry monster” or a “guard dog” who may be responsible for these anxious messages. Next, the ‘Check it’ step involves examining whether the thought may be inaccurate or extreme. Youth often benefit from a list of common ‘thinking traps’ to compare with their thoughts. Youth may want to check if the thought is helpful or interfering. If the youth determines that the thought is not helpful or that they are falling into a thinking trap, the third step, ‘Change it,’ provides an opportunity to respond to that thought with a more helpful thought. For younger children, this may be framed as arguing back to the worry monster. For older youth, this mustn’t be simply generating the opposite thought or telling themselves something they do not believe (e.g., I’m going to ace the test, not fail it). Rather, the function of this exercise is to achieve some cognitive flexibility by generating more reasonable, believable thoughts (e.g., I may get a B on the test, but probably won’t fail it).

Exposure Tasks (or “Behavioral Experiments” or “Challenges”)

The therapist creating/arranging exposure tasks is central to the effective implementation of CBT for youth anxiety (Higa-McMillan et al., 2016; Kendall et al., 2005; Peris et al., 2015). In addition to the therapeutic art of behavioral experiments (see Peterman et al., 2015b), there is ample evidence of their effectiveness. A meta-analysis of 75 studies of CBT with anxious youth found that effect sizes were positively and significantly associated with the amount of in-session exposure (Whiteside et al., 2020; see also Guzick et al., 2022; Peris et al., 2017; Wu et al., 2020). The field’s understanding of the mechanisms through which exposures affect change continues to advance, with recent findings suggesting that inhibitory learning models can be used to maximize their effectiveness (Banneyer et al., 2018). My view of “behavioral experiments” (exposure tasks) is that they have three parts: preparation, exposure, and post-exposure processing (see Tiwari et al., 2013).

In practice, before an exposure task, it helps when youth understand the reason for exposures or “challenges” or “behavioral experiments.” Metaphors, like slowly entering a cold swimming pool, can be used to describe their progressive and graduated nature. Additionally, the trust that comes with a collaborative youth-therapist relationship is important and extremely powerful for overcoming these “challenges.” The experience is best when the youth is positioned “in the driver’s seat” with the assurance that they will be asked to do things they do not want to do, but they will not be forced to do anything they are not yet ready to do. In planning exposure tasks, a hierarchy of feared situations with increasing difficulty is created. Of note, hierarchies are flexible, living documents that are adjusted as treatment progresses. To develop a hierarchy collaboratively, the therapist and youth (and may include the help of parents) set targets that serve as the goals at the top of the hierarchy. The therapist may generate many scenarios that could approximate steps to the identified goal. The youth ranks the scenarios and rates their perceived difficulty. The therapist can gain information about how to optimally design exposures by asking follow-up questions throughout this process (e.g., “Would it be easier if…or harder if…”).

When it comes time to engage in a feared situation and practice, it is wise to be explicit with the youth that they have agreed to do the task. It is also important to set specific and attainable goals. For example, for a socially anxious Latina preteen, the goal would be to “talk to a stranger without leaving the room before the 3-minute mark:” The goal would not be “Do a good job talking to a stranger”. Keep in mind that part of the benefit of a behavioral experiment is that the youth gets to test/challenge their expectation: ask the youth what they expect to happen in the task so that what actually happened can be re-examined afterward (post-exposure processing). Throughout an exposure, the therapist tracks the youth’s distress through the use of a predetermined scale (e.g., 1–10) and this information informs any adjustments that the therapist might make. For example, if the youth reports feeling so distressed that they anticipate escaping, it may be helpful to make the exposure slightly easier to allow the youth to meet the goal (back up but not back down). Alternatively, if it becomes clear that the exposure is too difficult for the individual, the therapist can work with them to adjust the goal mid-exposure (e.g., “Rather than stay for 4 minutes, how about we try for 2?”). This adjustment is done to facilitate experiential learning that counters avoidance responses to anxiety. Following an exposure task, youth are given an opportunity to assess their efforts, their performance about the objective goal, and the accuracy of their expectations. The experience (exposure task) typically provides evidence that the youth was able to cope and that the anticipated catastrophe did not happen. Rewarding the youth is associated with greater gains (Tiwari et al., 2013) and therapists provide praise, specifically focused on the effort put forth, rather than on a judgment of the outcome. For excellent suggestions of exposures, see Springer and Tolin (2020).

It’s all about making adjustments…within fidelity

A scientifically informed approach to therapy involves making adjustments that personalize the treatment while at the same maintaining fidelity to the key ingredients of the empirically supported treatment. Psychoeducation (e.g., normalizing and learning about anxiety), cognitive change (e.g., changing anxious self-talk), and exposure tasks (e.g., disconfirmations of anticipated catastrophes) are central features of effective CBT–and they can be implemented both flexibly and with complete fidelity. The phrase “flexibility within fidelity” denotes the need to administer treatment personalization while adhering to research supported protocols (Kendall, 2009; Kendall & Frank, 2018).

Let’s consider a few examples of “flexibility within fidelity,” using several of the required components: exposure tasks, homework, rewards, cognitive change, as well as a basic ingredient, the working relationship.

Flexible Exposure Tasks

Perhaps obvious, each youth has personal fears, and the effective behavioral experiment provides an opportunity to challenge these personal beliefs and expectations. A youth with Separation Anxiety Disorder will participate in exposure tasks that involve being away from caregivers, whereas a youth with GAD health related fears may participate in exposure to information, prevention, and treatment of the feared illness.

Even the same/similar exposure can be flexible. GAD often involves general worries about health and the future and comes with a high need for reassurance and a low tolerance for uncertainty (Kendall et al., 2020). A therapist and youth may discuss an upcoming behavioral experiment and the therapist may limit one child to asking a question only 2 times (limit reassurance seeking) whereas the same therapist planning a similar event with another child may, on purpose, leave some details unresolved (tolerate uncertainty). Although the same exposure task is being planned, adjustments can still be made.

Flexible Homework

Homework examples include calling a classmate to ask about a homework assignment, attending an after-school club event, sitting with someone on the school bus or in the cafeteria, asking to borrow something from a neighbor, or ordering your meal at a restaurant, etc. It’s all homework, but the task varies. Even the name for the task varies: for younger kids we refer to homework as a “Show That I Can” (STIC) task, underscoring that they are showing us that they can do it. For teens, homework is labeled as a “Take-home project.” The basic premise is this—homework outside of sessions is important, but there are adjustments for specific youth.

Flexible Rewards

One child wanted a scrunchie (hair holder), another wanted a Philadelphia Eagles knit hat, and another wanted to wear a parent-banned T-shirt to school. We purchase inexpensive rewards for youth (scrunchies), we request and secure sports materials from the local franchise (Eagles cap), and we negotiate privileges with parents—all rewarding to the youth.

A case example illustrates that the magnitude of the reward is less important and that the contingent “earning” of the reward matters more. A preteen Caucasian boy with a focused interest in aviation was doing a school report on the Wright brothers. In the session, he worked to earn a balsawood ‘throwable” toy airplane (cost about $3.00). At the same time, his wealthy father flew him to Kitty Hawk, North Carolina, to visit the aviation museum. Economically, the balsa toy was a drop in the ocean (easily purchased by the parent), but it was something that the boy was proud to have earned for himself. Rewards work when they are rewarding to the youth (not the therapist), and they need not be costly.

Flexible Cognitive Change

Youth do not typically want to be quizzed by an adult (therapist; perceived as an agent of society) about their thoughts (self-talk). Having self-talk that is burdened by anticipating potential catastrophe is a cognitive characteristic of anxious youth, and targeting change in self-talk is an active component of psychological treatment. The notion of “self-talk” is complicated (Latiniak, in press), but can be simplified for youth by referring to thoughts that “pop into your head” Or thoughts that you would see in a “thought bubble.” A therapeutic mistake, in my opinion, is when a therapist asks the youth too many questions OR asks, too soon, “What are you thinking?” Such an approach will likely result in answers such as “I don’t know” or “Nothing.” Instead, to be able to access the youth’s self-talk, the therapist sets the stage for talking about thoughts by sharing his/her own thoughts. For example, “Something just popped into my head—I have to remember to take my car for an oil change. I wrote it down; I hope I don’t forget.” After the therapist frequently “goes public with their private thoughts” the setting is one where talking about one’s thoughts is accepted and even expected. Once this is accomplished, the therapist can ask something akin to “What popped into your head?” Of course, it’s best if the first time this is done it is in a positive context—the youth is more likely to comply with an answer. Over time, after the practice of sharing self-talk is common, asking a youth “What thought popped into your head?” when anxious will more likely result in a genuine and honest reply.

Cartoons often use “thought bubbles” and it can be effective to use thought bubbles to access some of the youth’s self-talk. There are commercially available sticky notes in the shape of a thought bubble. Using a magazine of interest to the youth (e.g., Sports Illustrated for Kids; GameBoy; Teen Vogue) and selecting a photo of someone of interest to the youth, the therapist can place the thought bubble above the person in the photo and take turns generating sample self-talk. Photos of situations that are fun can be used first, followed by photos of situations where the person might be anxious. After generating thoughts (to fill in the thought bubbles), the therapist can ask if that thought would be helpful or interfering. Without judging, the therapist can guide the distinction between helpful and interfering self-talk, and even between likely and unlikely self-talk. More specifically, an individual might be ridiculed for not knowing the correct answer in class. However, being able to separate what is possible from what’s probable, with related self-talk, can help the anxious youth think (talk to him/herself) differently about the situation. Notice in the discussion that there is the fidelity to addressing and changing self-talk, and the flexibility, related to the materials used, the age of the youth, the youth’s interests, etc.

Flexible Relationship Building

It’s reasonable to believe that therapists who work with youth have some skills in building a relationship that is trusting and helpful. That said, there are some empirically supported relationship-building strategies that are important to implement when working with anxious youth. For example, pretending to be a kid, when we are not, is not something that is associated with youth assigning a positive therapeutic alliance. Also, talking too much and too soon about anxiety is associated with a lower rating of the therapeutic relationship. As previously stated, a collaborative style is positively associated with a higher youth-assigned alliance rating.

Attending to the relationship and being flexible with youth matters. Artistic youth can draw their body and indicate where they feel anxiety. Youth interested in movies or sports can search and find movie or sports idols with anxious fears and read the ways these idols have addressed their anxiety/fears. The relationship can be affected by the schedule. Be willing to change the schedule—if the youth’s appointment is at 4 PM, but the youth wants to go to the remote-control car after school club meeting, change the scheduled appointment. These examples can serve multiple purposes but certainly fit within the flexibility needed to build a strong working relationship.

Flexibility across Modalities: Computer Programs and Telehealth

For multiple reasons (e.g., accessibility of services) both computer programs and telehealth administration of psychological treatments for youth have increased. As an illustration of a computer program, consider Camp Cope-A-Lot (CCAL). CCAL has the same ingredients as the treatments considered to be effective in face-to-face application but is delivered via an interactive “camp” experience (for youth 6–13 years; See Dr. Khanna for details < muniyac@hotmail.com> ). Telehealth has expanded and psychological treatment of youth anxiety has been applied successfully via telehealth. Of note, findings indicate that 7–17-year-olds who were treated in-person versus those who were treated via telehealth had comparable outcomes (Rabner et al., 2024) and the outcomes were also in the same range as those reported in other trials. Of course, flexibility was a crucial aspect of these modalities. When the treatment/education is delivered via computer and exposures need to be implemented, the role of a “coach” is introduced. The role of the coach comes into play because someone who is suffering from an anxiety disorder is not likely to engage in an exposure task on their own. Therefore, a meaningful other person (e.g., coach) can help guide and encourage the youth into an exposure. Despite the program being online, a coach is nevertheless needed and provides for more flexibility in virtual therapy. Virtual exposures can be adapted by having the youth use tools such as Zoom or Facetime on their phones to generate that shared experience.

Treatment Goals along the Way

From an educator/collaborator perspective, psychological treatments for youth are not burdensome or painful, but a version of fun. Especially when rewards are earned for facing their fears and accomplishing exposures, youth feel a sense of uplift of mastery. Moreover, pleasant activities are purposefully built into treatment sessions. Games are played, and even when addressing topics such as emotions, the information can be done with drawings, playing charades or other fun-for-youth activities. Recall that the goal for the first session is for the youth to return for session two. This is, in part, accomplished by having the first session emplot a style that is NOT an in-your-face professional-to-child question-fest. The anxious youth comes to treatment “worried” about what will happen and likely anticipating the worst. We want the youth to leave the first session and think “That wasn’t so bad.” The first session can be for playing games and building trust —there will be time to focus on anxiety and it is best to not focus too much on anxiety too soon (see Creed & Kendall, 2005). Play and having fun lightens the interaction. Play is not the mechanism of treatment effects, just a vehicle for communication and maintaining interest.

Consistent with the “make it fun” theme, the last session is for some positive conclusions. The last session of Coping Cat is a celebration of the youth’s successes to date. For example, a socially anxious female teen began treatment at a time when she avoided school social activities but ended treatment at a time when she just went on a class trip. The last session allowed her to pick a treat (order pizza) and review her accomplishments. The therapist was sure to mention “I recall when we first met you were hesitant about social activities and now you just had fun on the class trip—round of applause for you!”

Treatment ends not for reasons such as funding ran out, the parent became tired of transporting the youth, or because the youth complained to the parent that he/she didn’t want to go anymore. Treatment ends, at a planned time, with reflections back on successes and looking forward to future challenges. The future will not be error-free but will require the application of what was learned to the new situations. One notion that has stuck with me throughout my career is a statement that I believe is a combination of something I heard from a supervisor and something I saw for myself: as a mental health professional working with youth, don’t be a stiff but “be ready to get on the floor and play.” Strive to have the youth come out of the session feeling happy and proud.

Parental Involvement

Parents (caregivers) are certainly a part of the psychological treatment of youth. They are not the sole agent of change, but they are helpers along the way. Parents provide information about situations that are troublesome for their child, disclose their less-than-preferred past efforts, and are informed of the plans for their child’s treatment and its goals. Parents are encouraged to be less intrusive, to model bravery, and to allow the child to have a chance for modest risk-taking. Parents are also informed about their accommodations (changing their own behavior to reduce the youth’s anxiety) and how such accommodations are not helpful and typically make anxiety more resistant to change. Parents of younger children and their accommodations can be the focus of treatment (e.g., Lebowitz, 2021) and parents can be included in the sessions for the youth or even involved in solely parent-based therapy to reduce accommodations. Child-focused and family-focused efforts have comparably favorable outcomes (Kendall et al., 2008). Parents may indeed be both competent to implement treatments/education for anxiety and help raise youth with less anxiety and more resilience (see Khanna & Kendall, 2021).

Epilog

Albeit simplistic, there are similarities between the psychological treatment of youth and piano lessons. Let the child tinker at the keys for fun, and never slap a wrist for a missed note. Let the youth pick the song to learn. Model how to play it, allow for imperfections, and model coping with the mistakes. Reward effort, not performance/perfection. In the end, after learning a song and having practiced both in lessons and at home, arrange for a recital where the youth “shows off” what they learned. End with a reward for performing (without judgment).