We sat down for a Q&A with Dr. Chloe Zachary to better understand the SPACE program, a parenting intervention designed to target youth anxiety.
Q: What does it mean to have a "parenting intervention" for a concern that is an internal experience happening for my youth?
A: Traditional cognitive behavioral therapy (CBT) for youth anxiety works directly with youth to change their own internal thoughts and behaviors. However, as mammals, youth anxiety is social by design! For example, when human infants experience fear, their biologically-programed response of crying is intended to communicate to their caregiver. This is adaptive behavior for young mammals who are dependent on caregivers to soothe and protect them. However, as youth develop, the goal is for them to become more self-sufficient in their ability to regulate their own emotions and keep themselves safe. Youth with anxiety disorders experience ongoing, often inappropriate activation of the fear response -- meaning they feel afraid in the absence of a true threat. As a result, these youth are also chronically activating the social signaling of fear to their caregivers. Thus, SPACE directly targets the interpersonal aspects of youth anxiety-- namely, how caregivers respond to their youth’s expression of anxiety and fear.
In SPACE, caregivers are taught to combine support and confidence in responding to their youth’s communication of fear (e.g. “I know it’s really uncomfortable and I believe you can do hard things!”). We then work to chart and systematically reduce caregivers' accommodation of youth anxiety. This can broadly be thought of as changes caregivers make in their own behavior to either participate in their youth’s anxiety (e.g. answering excessive youth questions, engaging in checking or other rituals for youth) or modify their own behavior (e.g. always being available by phone, changing work schedule to accommodate youth’s fears.) While accommodation comes from a loving desire to reduce a youth’s distress, this behavior provides a short-term fix but unfortunately maintains anxiety symptoms and increases youth dependence on caregivers to regulate their emotions. By reducing accommodation slowly, we give youth and caregivers the opportunity to see that youth are indeed capable of tolerating their anxious distress.
Q: Does SPACE assume that the parents have caused the anxiety concerns with their youth?
A: Not at all-- parents are not responsible for causing their youth’s anxiety but can be a huge part of the solution. If your youth had the flu, as a caregiver, you would probably change your behavior (e.g. not insist they go to school that day) and seek help to support them (e.g. call the doctor, obtain medication.) Nonetheless, we would not say a parent is to blame for their youth having the flu. We think about youth anxiety in a similar manner. Regardless of what various factors contributed to a youth’s anxiety, caregivers can take steps to help their youth overcome this challenge by seeking support themselves. Caregivers are often required to take unilateral action to ensure their youth’s well-being-- many youth would gladly opt out of regular doctors appointments if given the choice! SPACE empowers caregivers to help their youth with anxiety, even when youth are unable to choose this for themselves.
Q: Can SPACE work if only one caregiver participates? What about with divorced families that have two households?
A: It is very common for youth anxiety to be an area of contention between caregivers who may hold different beliefs about the best way to respond to this. In SPACE, we will work to directly address this and increase collaboration to the extent possible. As in most parenting interventions, consistency between caregivers is ideal. For youth who are part of two households, we work to increase communication and consistency across households to the extent possible. This could include having caregivers from both households actively participate or having the participating caregiver inform other caregivers of the steps they are taking. For instances in which only one caregiver is willing or able to participate, SPACE will focus on changes that caregiver can take to alter their own behavior. Even a single caregiver demonstrating confidence in their youth’s ability to tolerate the discomfort of being anxious sends an important message!
Q: Will SPACE work for our family even if our youth is not engaged in any treatment themselves?
A: SPACE is designed as a parent-only treatment and no youth involvement is required in any form of treatment. Research has shown SPACE to produce similar clinical outcomes to youth engaging in CBT individually. Both treatments showed similar reductions in clinician, parent and youth ratings of child anxiety and had similar levels of patient satisfaction.
All research published to date on SPACE treatment can be accessed here: https://www.spacetreatment.net/manual-and-books
Q: When would you recommend a family seek CBT for the youth's anxiety vs. SPACE with the parents?
A: SPACE is most effective when parents are in some way involved in their youth’s anxiety. This could be in the form of providing emotional support, working to reduce the youth’s anxiety by removing stressors or accommodating youth’s requests (or demands!) to avoid anxiety-inducing situations. If the youth’s anxiety is impacting the family, parents or youth-parent relationship, SPACE has material to work with.
If a youth’s anxiety does not involve caregivers in any way, CBT would be a better option. For example, a youth may feel anxious about taking tests but this does not impact the family or parent-youth relationship (e.g., the youth rarely seeks support from caregivers and never refuses to attend school). In those circumstances we would be more likely to recommend the anxiety be addressed directly with the youth in their own therapy.
In most instances, combining individual CBT for youth with SPACE for parents would be ideal as it allows two approaches to work simultaneously towards anxiety reduction. However, SPACE is a particularly great option for caregivers of youth who:
a) refuse to participate in individual treatment or are too young to effectively do so
b) have engaged in individual CBT but more change is desired
c) youth anxiety is significantly impacting the overall family functioning and/or the parent-youth relationship
d) caregivers are struggling to reach consensus on how to respond to youth anxiety