Daniel Knoepflmacher, MD (Host): Hello, and welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knufflemacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, neuroscientific research, and other important topics on the mind.

Our focus today is on youth anxiety. Anxiety is the most common mental health disorder affecting children and adolescents. A national survey of children's health found that almost 8% of young people between the ages of 3 to 17 years had a current anxiety disorder. of course, the COVID 19 pandemic only exacerbated this widespread problem.

It's no surprise that public health leaders use the word crisis when describing teen mental health in our country. To help address this. The U. S. Preventive Services Task Force suggested that all children and adolescents aged eight to 18 years should be screened for anxiety during pediatric medical visits.

While this measure helps identify the scope of a growing problem, it doesn't address the central question of how parents and medical providers can help the many anxious kids in our society.

Today, we'll delve into the reasons why anxiety is affecting so many young Americans identify what it looks like in children and teens. and explore how to effectively treat this condition.

To help do all of this, I'm grateful to have Dr. Angela Chu joining us on the podcast today. Dr. Chu is an assistant professor of psychology and psychiatry at Wow Cornell Medicine, working in the New York Presbyterian Center for Youth Mental Health. She has deep expertise in evidence based psychotherapeutic interventions for children.

adolescence and young adults suffering from anxiety and mood disorders. She's traveled nationally to train clinicians in psychotherapy for youth mental health problems.

I've personally had the pleasure of collaborating with her in the treatment of young adults, and I know her to be an excellent clinician and fantastic educator. Angela, Thank you so much for coming on the podcast today.

Angela Chiu, PhD: Thank you so much for having me.

Daniel Knoepflmacher, MD : We'll be talking about youth anxiety today. But before we jump in, I'd like it if you could share your story. I'd like our listeners to understand the personal context that shapes your expertise in this area. What was the path that led you to become interested in child and adolescent mental health?

Angela Chiu, PhD: Well, I think my interest in youth anxiety really stems from my own personal experience with anxiety as a child. When I was little, I desperately wanted to be viewed as smart and as competent. And I remember I had this little voice in my head that used to tell me, "You have to work twice as hard as everyone else if you wanted to avoid failure." And as a kindergartner, I begged my older brother to do his homework for him because I thought I needed the extra practice. And in elementary school, I had this very rigid routine for myself where I would come home and I wouldn't even allow myself to have a snack before I finished 90%, 95% of my work. And these were expectations I set for myself. My parents didn't set these for me. And I remember this salient morning in middle school when I actually got really sick and vomited. I hid this from my parents because I was afraid they would keep me home from school and that I would fall behind on my school work.

And it wasn't until college when I took psychology courses that I learned about anxiety disorders, and it was so liberating to learn about conditions that explained a lot of what I experienced. And it was so exciting to learn too that there were treatments for anxiety that were really effective. I was just hooked. And I found a graduate student to pair up with and started a senior thesis. And I got to listen to experts in the field do therapy, encoded these audiotapes, and that led me to assistant position where I helped to coordinate clinical trials for youth anxiety, youth depression. And it was in this work that I learned that there was so much mounting evidence for treatments for youth anxiety and youth depression. But the dilemma was that children and adolescents weren't getting access to these treatments and I thought that that was such a grave injustice and it sparked a passion in me to want to go to graduate school so that I could study how to extend the reach of evidence-based treatments so that everybody could have access to them. And I think this passion really was a thread that weaved throughout all of the work that I've ever done in my career, including developing treatments, testing treatments, training clinicians on evidence-based treatments for youth, consulting with agencies around how to build workforces to deliver evidence-based treatments for children and building evidence-based programming in the partial hospitalization programs for emerging adults with anxiety, which is where we met.

Daniel Knoepflmacher, MD : Yeah. I mean, I knew about the end of that story. I did not know about the beginning, which is fascinating and makes so much sense that you naturally would have so much empathy for the children you encounter in your work. And thank you really for sharing that. I mentioned what many have described as a youth mental health crisis in our country. Can you give us a clear overview of what's going on and why you think these problems have been getting worse?

Angela Chiu, PhD: Sure. Well, the youth mental health crisis really refers to data that's really alarming about how our youth are doing emotionally in our country. And to give you some context, even before the COVID-19 pandemic, the rates of anxiety were already on the rise. And unfortunately, the COVID-19 pandemic only exacerbated these trends. A meta-analysis, which is a study that aggregates data across multiple studies reported that across 80,000 adolescents, there was a two-fold increase in the prevalence of clinically significant depression and anxiety among adolescents after the COVID-19 outbreak. And there was more too. There were increases in the volume of mental health-related emergency department visits following the COVID-19 outbreak, we saw surges of 31%; and among adolescent females, an increase in 51% in terms of suicide-related emergency department visits after the COVID-19 pandemic.

So, all of this data cumulatively really prompted, I think, the US Surgeon General to release a report, and that was back in December of 2021, that we were in a state of emergency because of this youth mental health crisis. And back then, there was already a report that was released by the Children's Hospital Association, the American Academy of Child and Adolescent Psychiatry, and the American Academy of Pediatrics really saying the same thing, that we were in a national mental health crisis with respect to youth mental health.

And the biggest issue, which is still an issue now, was that we didn't have an infrastructure. And we didn't have enough providers to meet this surge in need. And what happened was that because of all of the referrals, a lot of our youth mental health clinics became fully saturated, and there were really long wait lists for appointments. Private clinicians don't have availability. There were really limited options for insurance-based care. And as a result, emergency rooms ended up getting flooded. And it's really sad because children and adolescents were waiting in emergency rooms to get treated for really long periods of time. Lengths of service were far exceeding the standards of joint commissions, and it was really because we didn't have enough child and adolescent inpatient beds to meet the need. And so, I think the reason why we're in this boat right now is because COVID-19 really exacerbated trends that predated the pandemic and exposed the fact that we just don't have an infrastructure that can meet this surge.

Daniel Knoepflmacher, MD (Host): The pandemic really did uncover structural problems in so many areas and one specific Stark reminder of that is, the memory of all those children waiting in the yards for days to get the treatment they needed. I remember seeing that whenever I went down to the ER. I want to turn to. Youth anxiety specifically as a topic for us to focus on.

And I, want to ask you about what it looks like at different ages of development. Can you describe how anxiety presents differently or similarly in younger children versus teens?

Angela Chiu, PhD: I actually think there are a lot more similarities than differences across the age spectrum. One major difference, though, is the source of the anxiety. So, younger children tend to be fearful of external things like insects, like the dark, monsters under your bed. My seven-year-old is terrified of lava getting him at night, robbers breaking in. Whereas once you get into adolescence, teenagers are much more concerned about how they themselves are being perceived by other people. So, social evaluation, their school performance, how they perform in sports, how their bodies are changing become more major sources of anxiety. And even though teenagers are better at hiding their thoughts and anxiety and they're probably much more likely to be irritable, there are some hallmark features of anxiety that you see across the age spectrum.

So, you see worrying a lot. Children with anxiety just worry excessively and their worry is just out of proportion to the context. Kids with anxiety have physical symptoms, and it's because anxiety is our body's alarm system that alerts us to danger and because anxiety is part of our nervous system. Children report headaches, stomach aches, body aches, nausea, bladder urgency, racing heart, and it's really common for youth to report these symptoms right before or during a feared situation, but not at all during other times. You'll also see avoidance. So, children and adolescents will avoid what they're afraid of, and that's instinctively what we tend to do when we're afraid of something. We run away from them, those situations. So, you'll see avoidance. And you'll also sometimes see what looks like disruptive behavior, so lashing out, explosive outbursts, acting aggressively. And this is not disruptive behavior because you don't tend to see this indiscriminately, you know that this is anxiety-related because they're really like preemptive strikes. They're desperate attempts to avoid an impending scary situation, they only tend to happen right before a feared event. And then, you'll also see reassurance-seeking, asking the same question over and over again. "Am I going to be late? Am I going to be late? Am I going to be late?" And then because of the worries, you'll sometimes see disruptions in sleep and difficulty concentrating. So, these are some of these hallmark features that you tend to see that are good signs that anxiety might be present.

Daniel Knoepflmacher, MD : That's really a helpful distinction. It's about the cause of the anxiety that's the biggest distinction. But some of these somatic symptoms and avoidance patterns, those would be the same in an eight-year-old as in a 15-year-old maybe.

Angela Chiu, PhD: That's exactly right.

Daniel Knoepflmacher, MD (Host): We've been using the word anxiety, I think, very broadly in this context, but there are many specific types of anxiety. Can you provide us with a brief overview of the specific anxiety diagnoses that are most common among children and adolescents?

Angela Chiu, PhD: Sure. Well, there are actually a lot of anxiety disorders that are listed in the current version of the Diagnostic and Statistical Manual of Mental Disorders. I'm happy to go through some of them that are most common in children and adolescents.

We have generalized anxiety disorder that you mentioned before. And kids with generalized anxiety disorder just worry a lot. And they worry, as the name implies, about lots of domains of life. The anxiety has been generalized. So, they jump from one category to the next. They really are just worry hoppers, if you will. They might worry about finances, about their health, about their family's health, about their friendships. And they tend to experience physical symptoms along with their worry, and they're just always on edge.

Then, we have separation anxiety, which is much more common among younger youth. Kids with separation anxiety are afraid to be apart from their loved ones because they're worried about something bad happening to their loved ones, like an accident where they won't see them again, or something bad happening to themselves, that they might get kidnapped. And so, these children are afraid often to sleep on their own, to be apart from their parents. Even at home, they might shadow their parents around the house, and they might struggle with separation with respect to going to camp or going to school.

We also have social anxiety disorder, which is much more common in adolescents than younger youth. And this is when someone is fearful of humiliation, is fearful of being judged negatively by others. And youth with social anxiety disorder often want to avoid situations that are social in nature, where they have to perform. So, they might decline an invitation to a party, they might struggle to have conversations, they might not eat in the cafeteria or might struggle to raise their hands in the classroom.

We also have panic disorder, which is also more common in teens than in younger kids, and it's marked by recurrent, unexpected panic attacks. And then, that's paired with a worry about having the next panic attack. And panic attacks are really defined by a sudden surge of intense fear that often reaches its peak within just a few minutes. And it is associated with a host of physical complaints as well as some thoughts like "I'm going crazy" or "I'm going to die."

We have agoraphobia, which is a fear of going into places where escape might be difficult or embarrassing. So, these individuals avoid crowded spaces, the subway in New York City; Ikea, which only has one entrance and one exit. And then, we have specific phobias, which is the most common type of anxiety disorder. And as the name implies, it's a phobia or fear of something specific, a specific situation or object like injections, animals, transportation, vomiting.

And last but not least, we have selective mutism. And children with selective mutism usually develop this disorder early on in life, but it can persist into adulthood if it's left untreated. And this is when kids can talk actually when they're in comfortable situations. But when they're in novel situations or uncomfortable places like school, for example, they might freeze up and not be able to speak.

Daniel Knoepflmacher, MD : Thank you. It's quite a variety. And you explained each of those so clearly, Again, I'm thinking about this distinction between the stresses of life and the point at which it becomes a disorder. And there is psychological research that shows how stress in certain situations is a maybe not pleasant, but beneficial experience in terms of motivating people to get things done, to meet responsibilities, to achieve. Can you help us untangle the stress from the anxiety? Where does one start and the other end? When does this start to be a problem?

Angela Chiu, PhD: That is a great question because stress and anxiety are terms that are often used interchangeably and there are a lot of similarities. Both are emotional responses. But stress and anxiety have different origins. So, stress is really a normal reaction to everyday pressures, which are typically external. So, pressures can be short term, like finding out that you have a deadline for a project or getting into a fight with your best friend. They can also be long term, like living with a chronic medical condition or living in a community where there's a lot of violence. Some stress, like you mentioned, can be helpful. It can actually prompt you into action to be able to start working on that long-term project. But when there's too much stress or prolonged stress without a lot of breaks, that can really take a toll on your health. And when you're under distress, it's common to exhibit symptoms like anger, irritability, fatigue, muscle pain, difficulty sleeping.

Anxiety, though, in contrast, its origin is internal, and it's really defined by marked, persistent, excessive worry that doesn't disappear even in the absence of a stressor. So, you don't necessarily need an external stressor to have anxiety. And in fact, stress is a common trigger for anxiety, but it's really confusing because anxiety can also lead to a very similar set of symptoms.

Daniel Knoepflmacher, MD : That's a very, very helpful distinction. And when you're talking to parents who are worried about their children and whether or not they have anxiety, how can you help parents understand when a child's anxiety has reached a threshold that might benefit from treatment?

Angela Chiu, PhD: I usually suggest reaching out if you start seeing signs that your child's anxiety is starting to get in the way of your child's daily life. Or if you notice that your child is enduring his or her everyday life with tremendous distress because of the anxiety. And what I mean by interference with daily life is that anxiety can make it really difficult to go to school, stay in school, to do homework, to turn in assignments, to participate in extracurricular activities, to make friends, keep friends, engage with family members, sleep, eat, exercise.

So if you're starting to see signs that anxiety is making it difficult to do those things, reach out. And in general, I say reach out, don't wait, particularly because we are in a youth mental health crisis, which means that there are often, unfortunately, long wait lists to get into centers and clinics that specialize in working with children and adolescents. And this way, if things worsen or persist, you've already gotten a head start. So, I really strongly suggest reaching out early if possible.

The other reason is because one of the most robust predictors of poor outcomes in treatment is actually having higher severity of anxiety at the start of treatment. So, it's a really good idea to access treatment when anxiety levels are more mild to moderate. And especially if anxiety is starting to lead to difficulties going to school regularly, we call that school refusal, I definitely suggest connecting on the earlier side because these types of presentations don't tend to remit on their own without intervention. And the good news is there's really effective treatments. We have very effective treatments in centers like ours in the Center for Youth Mental Health.

Daniel Knoepflmacher, MD (Host): Certainly, you and I encounter many stories of children suffering from anxiety. These are kids who need to get help as soon as possible. The Surgeon General, Dr. Vivek Murthy, has focused on the mental health crisis in our country and he issued a statement a few months ago about social media. He said that it poses a risk of harm to the mental health and well being of children and adolescents.

95% of adolescents use social media frequently, and I'm sure that statistic might even be low, and that's something that comes as no surprise to anyone who knows teens. Can you comment on how social media plays a negative role when it comes to adolescent anxiety?

Angela Chiu, PhD: Well, the research on social media use is still very much in its infancy, but there are signals that social media use, and particularly excessive use, is associated with mental health consequences. For example, one study showed that adolescents who spent more than three hours on social media doubled the risk of having poor mental health outcomes, which included anxiety symptoms and depression symptoms. And this is really alarming, considering what you just mentioned, that we know that teens use social media ubiquitously. And there are reports that about a third of adolescents are on social media constantly throughout the day. We know that excessive social media use is also linked with feelings of exclusion, preoccupation with appearance, lower body image, eating disorder symptoms. And social media use has also been linked with poor sleep and difficulties with sleep, reduced sleep duration. And social media use is also associated with just a whole host of other untoward outcomes.

Interestingly, there is some data that suggests that limiting use can actually have positive mental health effects. So, there's been a few studies suggesting that capping the use to about 30 minutes per day or deactivating social media accounts for a short period of time can lead to decreased depression symptoms, decreased anxiety symptoms, increase in life satisfaction. So, I think that data is quite interesting that it's not social media use blanketly that's a problem, but there may be some room for sort of containing that use. But the bottom line is that we don't have enough evidence at this point to ensure that social media use is safe. And that's why the US Surgeon General issued that call for researchers, tech companies, family members and policymakers to all have this shared responsibility for better understanding what is the impact of social media use on our youth so that we can make sure appropriate safeguards are in place.

Daniel Knoepflmacher, MD : And certainly, the limits there, there is some evidence of that. And 30 minutes, wow, that sounds pretty dramatic based on the use I've seen of the teens around me. But that's pretty promising data there. I had an episode earlier where I spoke with Dr. Amy Lemelman and we were speaking about autism. And she was bringing up cases where social media actually creates some community and sometimes even education, sometimes miseducation, but other times education about autism spectrum disorder. I'm wondering about your thoughts about notable examples of helpful social media.

Angela Chiu, PhD: Well, the Pew Research Center has run surveys with teens on social media use. And teens report a number of benefits of social media use, including feeling more connected, feeling more accepted, feeling like it's really positive to have a venue to be able to express oneself creatively and feeling accepted. So, there are notable positives to social media that have definitely been documented. And like Dr. Lemelman mentioned, social media is really effective at disseminating information. The problem is that there's also misinformation out there too.

But one area that I am very excited about that's burgeoning is how social media and social networking sites can be used as a gateway to access mental health interventions. So, there was a study that was published last year by Jessica Schleider's group, and it was a randomized controlled study that used Instagram to recruit youth and found that a single free intervention of behavioral activation, which is a fancy term for teaching kids to engage in activities to interrupt the cycle of depression, or a single intervention that talked about how traits are malleable, that those kids that received that single intervention had decreases in depression symptoms, decreases in hopelessness, decreases in restrictive eating and an increase in a sense of agency compared to a control group. So, I think a study like this has really important implications that social media may actually be a vehicle that can help close gaps and inequities and access to quality mental health intervention. So, I think there is a lot of potential for social media to be beneficial.

Daniel Knoepflmacher, MD : So, it's a really double-edged sword. As you were saying before, there's clearly problems with overuse of social media. Do you have any tips that you give parents about realistic steps that they can take to reduce the harmful effects of social media on young people?

Angela Chiu, PhD: Well, I don't have any solutions, but I do have ideas. One is that just like we need a healthy balanced diet when it comes to nutrition, we also need to work on habits that promote a healthy diet when it comes to screen time and social media use. And children need explicit help to create these healthy routines and help sticking to them too. And as they show more skill, we can remove those guardrails just like we would with developing any other skill. And I can't tell you how often parents come up to me and say, "I don't know what to do about social media use. I don't know what to do with screen time." And it's tricky because, in part, parents often are less tech savvy than their kids are. Teens are asking for more privacy, which is developmentally appropriate. And parents don't want to rob them of important opportunities to connect with their peers. And teens are also saying they're relying on their smartphones to cope with stress, to cope with anxiety, and they also need their screens for school. So, it's really complicated.

And one tip that I like to tell parents who are wrestling with this is that you really want to apply the same amount of oversight and supervision that you would online that you would in person. So, let's say your child wants to invite a friend over. Are you the type of parent who wants to know that child's name? Are you the type of parent who wants to know if an adult is home to supervise? Are you the type of parent who would want the door left ajar so that you can peek in and see what's going on? Are you the type of parent who wants to be able to monitor the situation? Well, if you are that parent that wants to know the name of the kid and would monitor and be there to supervise, then you can aspire to provide that same level of oversight online than you would in person. It just feels a little bit weirder to sign into a social media account to read through posts or to read through your child's text messages. But if you're doing it anyway in real life, you should also do it online.

I also find that creating a family media plan is really helpful. And this is a written plan that outlines agreed upon expectations for technology use and boundaries. And it actually delineates when are screens okay, when are screens off-limits, which sites are okay, which sites are off-limits, which sites will parents be monitoring, how often will they be monitoring, and what are the expectations for the youth to follow, and then what happens if they violate these expectations. And I think having that plan clear-cut is really helpful for families, so things are very explicit. And you can easily Google family media plans online. The American Academy of Pediatrics also has a nice template and lots of tips on their website, which is www.healthychildren.org.

But my general advice, which is similar to everyone's advice, is teach your children and model for your children how to be good consumers of information, watch out for misinformation, teach good digital citizenship, good digital etiquette. And as our US Surgeon General mentioned, the responsibility shouldn't fall solely on parents and for youth to protect themselves, that everyone needs to get involved, researchers, policymakers, tech companies. All of us have to share this responsibility to better understand social media use and ensure that we have safeguards in place.

Daniel Knoepflmacher, MD : Practice what you preach is modeling for the kids and teens in your house. You've given us some helpful tips. I want to speak more about how we can help families and teens and kids to discuss some of the treatments that are effective for anxiety. You've done a lot of work teaching and supervising psychotherapy for youth anxiety. Can you give us a brief overview of the leading evidence-based treatments?

Angela Chiu, PhD: Sure. So, the largest randomized controlled trial to date comparing therapy, medication, their combination, and placebo in youth with anxiety disorders found that almost 60% improved significantly from a full dose of cognitive behavioral therapy or CBT for short. And when CBT is combined with anti-anxiety medication, 80% improved significantly. So, the bottom line is that treatment for anxiety is very effective and the gains are maintained over time, even after treatment is over. But I want to be really clear about this piece, which is that CBT is a family of psychotherapy that teaches the connection between our thoughts, our feelings and our actions. But it's used to treat a variety of conditions. And the CBT that's effective for treating youth anxiety has to be tailored to the specific anxiety disorder. And CBT for specific anxiety disorders tend to include two main ingredients. exposure and a skill to manage our unhelpful thinking.

So to talk about exposure, if you laid out all of the treatment manuals that have been shown to be effective for youth anxiety, 90% of them, actually over 90% of them, include one ingredient, exposure. And that means that if you're looking for treatment for youth anxiety, you want to make sure that the provider includes exposure into their treatment approach. And this is about helping youth to practice facing their fears head on. And the rationale is with repeated practice, youth develop skills for how to navigate these situations. And as a byproduct of that, we tend to have less anxiety and we build our confidence level when we get practice. So, that's a really important ingredient, exposure.

The second ingredient, managing our unhelpful thoughts teaches youth that we have thoughts In our heads that stream through our minds all day long and we often treat our thoughts as fact or as a given. But our thoughts might not always be true. Sometimes we have thoughts that turn out to be incorrect. Like I had a thought that I was going to fail my licensing exam and I actually passed. So, this skill is about recognizing that our thoughts can sometimes contain thinking traps. And when we feel anxious, we tend to engage in two types of thinking errors, overestimating how likely something bad is going to be, and then blowing out of proportion how big of a deal that is, catastrophizing. And so, this skill is really about helping youth to notice when they have these types of thinking traps and to use strategies to reframe those thoughts so they're more helpful.

Daniel Knoepflmacher, MD : So with the high success rate of these treatments, I mean, 80% for combined treatment, you're really helping these teens or kids develop skills and ways of coping that can translate into better coping as adults. Like by intervening early, you may be helping them later in life.

Angela Chiu, PhD: Certainly. These are skills that individuals can take with them and use and hopefully use for a lifetime. And for some youth, they're really reclaiming their lives when they learn these strategies. One of them that I like a lot is living the exposure lifestyle, which is every day making a point to lean into anxiety and to practice facing what you're afraid of, even though it's uncomfortable so that you can feel more confident that you can navigate these situations. These are skills that you can carry with you into adulthood and beyond.

Daniel Knoepflmacher, MD : So, these skills that people learn are really universal. And in our country, there's so many people facing anxiety. In New York, we have this incredibly diverse population and that's true in many places across the country. And anxiety is a universal human experience, but there are really different factors affecting individuals and communities in unique ways. You talked about stress earlier. There's different stresses that could be chronic in different places and in different settings. Can you speak about, as a therapist, as somebody who's helping young people get better and face their anxiety and really recover, how you can be culturally sensitive when you're addressing the needs of patients from so many different backgrounds?

Angela Chiu, PhD: Certainly. Well, I try to practice cultural humility, so I try to be reflective about the aspects of my own identity that are salient to me, the aspects of my identity that are more privileged, the aspects of my identity that are marginalized. And I appreciate that I walk into therapeutic relationships with biases, and I try to stay cognizant of that. I also deliberately ask my clients about their lived experiences. I ask them about whether they've experienced racism, marginalization, discrimination. I ask about how they identify and what values are most important to them. And because I work with children, adolescents, young adults, I really want to know how their value system fits or maybe doesn't fit with the value systems of their family members.

One really important shift that I've made to try to be more culturally sensitive in my work has been how I deal with cognitive restructuring, which is managing those unhelpful thoughts, what I was referring to earlier. I'm very careful never to question the validity of my client's experience when they report that anxiety comes about during incidents of racism or discrimination. And this is because I want to avoid enacting a microaggression that could exacerbate their anxiety, that could rupture our relationship and could be a deterrent for their progress.

And I'll give you an example just so that I can walk through the approach that I typically would take. I was working with a young adult who was multiracial and had social anxiety disorder and he disclosed that walking down the street was terrifying for him. And it was mostly because he was afraid that people would look at him and judge him because of his stature, he was a pretty large male, and because of his skin color and because he was black. And he said, "I'm afraid that people see me as dangerous." And so, I was really careful not to challenge his experience. And what I tried to do is give him space to talk about, "Well, what does it feel like for you to walk around New York city, in the streets of New York City to go to work every day and to come back from work every day?" And we reflect it on how sad it was actually that we live in a world where these types of really painful things happen and occur. And we did use cognitive restructuring, but not for his experience of racism, but because he had internalized some of these experiences and wondered whether he was rotten, he was bad, he was dangerous, maybe he was a monster because of his race and because of his stature and because of his skin color. So, I will use skills to modify thinking, but I'm much more mindful about how I use it. And I think that's really important if you're trying to be culturally sensitive.

Daniel Knoepflmacher, MD : Thank you for sharing that example. I mean, it's such a great illustration of how to use cultural humility and really forge what sounds like a very effective therapeutic alliance. And, you know, for all of the people that we're helping to feel seen and understood is just so fundamental to this work. And I really like the way that you describe that. It's, I think, really helpful.

And on a more positive note, as we're talking about mental health crisis, I want to go back to what you said earlier about the fact that the treatments work, which is very promising, 80% for combined treatment. But also, the fact that in this crisis, there are times when a young person is waiting for an appointment or is not able to get care or maybe even they're in care, but there's times in between appointments. So, I'm curious if you could share some effective interventions that parents or kids themselves can employ on their own without a therapist guiding them.

Angela Chiu, PhD: Well, I mentioned this phrase earlier, but I really encourage everyone who battles with anxiety to live the exposure lifestyle. And it's mostly because of the evidence that exposure is an important ingredient in treatment. And there's emerging data now too that there's a dose response relationship. So, the more that you practice facing your fears, the better your outcomes are. So, live the exposure lifestyle to the extent that you can. I had a client that really liked this motto and said, "Dr. Chiu, I am embracing this. I am living the exposure lifestyle." And what that meant to her was that every time she was invited to do something with friends, even though she had generalized anxiety disorder, so worried about everything, she said yes.

And what I loved about it was that she really took a lot of the pieces to heart. She would set up these behavioral experiments when she said yes and say, "Well, I have a goal to do X, Y, or Z during this practice." It might be learning about a fact when I have brunch with someone, or I'm going to talk to at least two people when I go to this party. And she would think about in advance, "What am I worried about happening?" She would take anxiety ratings, using a 0 to 10 scale. And then, after every practice, she would debrief with herself to check in on whether what she thought was going to happen actually did happen and if it did, how she coped with it, and then her takeaways. And the lessons that she learned were so incredible. And just to tell you a little bit about this one client, her anxiety ratings were sky high and never improved over time. We usually don't see that. We usually do see some decrease. But she saw the value in facing her fears and being courageous in this way. And she made so much progress because she lived the exposure lifestyle.

Daniel Knoepflmacher, MD : I love that. I've never heard the exposure lifestyle, making it like aspirational. You know, maybe that could blow up on social media. Well, you know, Angela, it's just so great to have you here and talking about this because this is such a big problem that faces the young people in our country, but you've gone through it and broken it down for us, given some hope by talking about specific steps that parents and kids and teens can take. So, I'm going to end this episode as I do everyone on this podcast, which is to ask you, Angela Chiu, what are the main things you do to support your own mental health? Can you just leave us with a few personal tips?

Angela Chiu, PhD: Sure. Well, my own judgments are my worst enemy. And I still live with that self-critical voice, and it's changed over time. Now, it tells me I'm not doing enough. And this voice actually became much more pronounced when I had children. So, I use a skill called the three C's. I actually teach it to almost all of my clients to help me manage these judgments and it stands for catch, check, change the thought. You probably are very familiar with it.

So, the first step is notice the thought, notice the judgment, so "I'm not doing enough." And then, take a look at it, check it. And I used to check thoughts exclusively for how accurate they are. And now, I just care about whether they're helpful. Are these thoughts helpful or not? And that thought, "I'm not doing enough," is never helpful for me. It usually just makes me feel guilty and demotivates me. So if a thought is not helpful, then you move on to the third C, which is change it. It's not finding a positive slant on your judgment. It's trying to come up with a modification to that thought that is just more helpful.

So, the current iteration that I'm working with is, "This is my anxiety talking, it's not me." I know that when I'm present as a mom, I am not excelling at work. When I'm working really hard, I am not excelling at being a mom and that's okay. It doesn't mean that I'm failing. It just means that I'm human, and it's very long, but it resonates with me because it feels honest. And I think that's the key, is if you use this skill, keep on iterating until you find a version of a changed thought that feels honest and genuine. And if it's something that you could actually believe in the moment, then you probably have a winner. So, I really like the three C's. I suggest using it. I actually even took part in building videos on skills for coping with the pandemic, including the three C's, which I'm happy to share. They're free and available to the public, and it's a wonderful skill, so I hope people take it and use it.

Daniel Knoepflmacher, MD : Well, we can include that link with the podcast. And you know, I think that mantra that you have is not just honest, but it's also really forgiving. And I think that's an important part of this. But thank you so much. Thank you for being so open and sharing so much about yourself, but also really providing us with such a better understanding of this widespread problem and you've offered valuable guidance on what can be done. I'm hoping I can have you back again because I know there's many other things you can talk about and we can learn a lot more from you, but just thank you so much for joining us today.

Angela Chiu, PhD: Thank you so much. It's been such a pleasure being here today.

Daniel Knoepflmacher, MD : And thank you to all who listened to this episode of On The Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on all major audio streaming platforms, including Spotify, Apple Podcasts and iHeart Radio. If you like what you heard today, tell your friends. Give us a rating and subscribe, so you can stay up-to-date with all of our latest episodes. We'll be back soon with another episode. Speak to you then.

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