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(p. 59) Addressing Accommodation 

(p. 59) Addressing Accommodation
Chapter:
(p. 59) Addressing Accommodation
Author(s):

Eli R. Lebowitz

DOI:
10.1093/med-psych/9780190869984.003.0006
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date: 29 November 2020

The current chapter begins the “deep dive” into the work of addressing and reducing accommodation in cases of childhood anxiety disorders. This chapter includes suggestions for explaining to parents and children the rationale behind targeting family accommodation, creating an accommodation map that describes the accommodations currently being provided, and selecting an area of focus or specific accommodation to reduce. The next two chapters will discuss how to increase parental supportive responses to child anxiety and how to craft effective plans for actually reducing accommodation. The two following two example cases illustrate the implementation of these processes.

Explaining the Rationale for Targeting Family Accommodation

While some parents may welcome parent work, others may wonder why a child psychologist is trying to work with them rather than, or in addition to, their child. Parents open to meeting with their child’s therapist may still be taken aback by the focus on their own behaviors and expect that the therapist wishes to keep them up-to-date regarding their child’s therapy or to offer emotional support. Orienting parents to the importance of addressing family accommodation and to the goal of modifying their own behaviors can play a key role in successful intervention around family accommodation.

As discussed in an earlier chapter, parents may also feel apprehensive about being criticized by the therapist and wary of being “weighed, measured, and found wanting.” These sentiments also need to be dealt with, and hopefully eliminated, for a productive therapeutic alliance to ensue. The following discussion offers some suggestions for introducing the topic of family accommodation, making use of metaphors that can be easily understood by parents. Metaphors can be powerful tools in therapy and are often used in the treatment of anxiety. Therapists treating anxiety often use metaphors to externalize the anxiety and help a patient to see their anxiety symptoms as an “external force” to be resisted and challenged. In dealing with accommodation metaphors that help parents and (p. 60) children to see the accommodation as a natural and healthy response, but one that ultimately limits the child’s ability to cope independently, can likewise be highly useful. These suggestions are neither exhaustive nor exclusive but can be helpful to a therapist seeking to establish a fruitful partnership with parents who feel energized rather than defensive.

Talking with Parents

The Hijacking Metaphor

Anxiety disorders are the great hijacker. An anxiety disorder takes healthy, necessary systems and makes them run wild. Each of your child’s anxiety symptoms is a great example of this. His body does exactly what it’s supposed to when he’s anxious—rev up! This is a healthy defense mechanism designed to help him stay safe by giving him the power for fight or flight. But his anxiety disorder has hijacked this system and makes it “turn on” at the wrong moments and much too frequently. Their worried thoughts are exactly the same. Humans have the capacity to worry because it’s a great thing to have! Imagine if we needed to wait until a danger was right there happening in front of us to take protective measures to prevent it. That would be terrible, right?—for example, if your kid had to literally see the truck bearing down on him to take precautionary steps when crossing a street or if your house had to be on fire for you to think it might be unwise to play with matches. Terrible! But his anxiety disorder makes him feel like there’s always a truck right there. Or like the house is always just about to catch on fire. It’s a healthy and literally critical anxiety system, being hijacked by the anxiety disorder. He can’t sleep when he’s anxious? Of course, he can’t! What would be the point of an anxiety system that made us feel all nice and comfy so we cheerfully drifted off to sleep, while catastrophe was striking around us. No, his anxiety is supposed to keep him up, alert and ready for action! But once again the anxiety disorder, that great hijacker, is taking a useful and healthy system and turning it into a problem by making him feel that the catastrophe is always happening. So, he never gets a good night’s sleep.

There’s another aspect to kids’ anxiety response that’s just as healthy and beneficial as their body revving up or their thoughts being worried. And anxiety disorders hijack that system as well. When kids are anxious they look for their parents. And they should! Imagine if a three-year-old who was being attacked by a dog thought “I’d better fight this dog off all by myself. Of course, I could cry and let my parents know that I’m in danger, but nah, I’ll just deal with it” Good plan? Terrible plan! Kids are supposed to look for their parents— to call them and get their attention when they feel threatened. It’s what keeps us alive until we’re old enough to actually protect ourselves. A baby who tried to “go it alone” wouldn’t get very far, would they? But here comes the anxiety disorder that hijacks this great system, too. So what’s a kid who feels threatened or scared all the time going to do? They’re going to look for their parents all the time. They’ll call them, (p. 61) cling to them, yell for them, pester them. Because they’ve decided they want to be annoying kids who drive people crazy? No, because they’re doing exactly what they’re programmed to do, what they’re supposed to do—which is whatever it takes to trigger the other part of this great system. Because we, parents, are programmed too. We’re programmed to notice when our kids are in danger or upset and to help them get safe and feel better. Imagine if the mom of that toddler being attacked by a dog heard her crying out and thought, “Ah, she’ll be fine. I could go check on her because she’s screaming bloody murder but I think I’ll take a nap instead.” Not exactly mom of the year, right? We are the opposite way. Some parents feel like a little part of them hasn’t relaxed since their first child was born. Because there’s always that preparedness, that sensitivity to notice if our kid needs us. We’re supposed to step in when they feel scared. So we do it. But we’re just as hijacked as the kid. A child’s anxiety disorder takes over this beautiful system of child signaling and parent responding and makes it run wild. Just like the racing heart and thoughts.

And because we’re being hijacked, we have to get suspicious. We need to suspect that when these systems are being triggered, it may not be because they’re actually needed but because they’ve been hijacked. We want your child to notice his heart racing and think “I know why this is happening. It’s because of my anxiety disorder. I’m not in danger. And I don’t need to do anything to stay safe. I just need to wait a bit and I’ll calm down.” When he starts thinking like that he’s half way to being done with the anxiety disorder. And we need you to be suspicious as well. We need you to suspect that when your child is pushing your sensitive-parent role button it’s not because they actually need you to step in and help. It’s because the great hijacker is back. In fact, if you do step in, your child is not going to think, “I just need to wait and I’ll be calm” or “I wasn’t really in any danger to begin with.” They’re going to think, “Thanks, Mom, you really saved me there! I hope I can rely on you to do it again next time.”

Independent Coping

Children are lucky because they have two systems for coping with anxiety. They have an independent system, where they learn to regulate their emotions and “get back to calm.” And they have an attachment system where they can use a parent to “get back to calm.” This is great because it means they don’t always have to calm themselves. And, at first, children rely pretty heavily on the attachment system. It’s really powerful. Just being near a parent, or seeing them, even just hearing their voice can bring a child back to calm. It’s like when a small child falls and parents give them a kiss to make them feel better. If someone was studying human behavior scientifically, they might conclude that parents’ lips secrete painkillers. What’s really happening, of course, is that a tender kiss from a parent is an attachment signal. It helps to calm us down and can make us feel better. Over time, kids usually start to make more use of their independent systems. Teenagers don’t usually want a kiss when they fall. They do other things. Like rubbing where it hurts, (p. 62) distracting themselves, hopping about, or just waiting for it to pass. It’s the same with fear. Over time, kids start to make more use of their independent ability to calm down. They may not hop about as with a stubbed toe, but they find other ways to distract themselves, or they talk themselves down, or they take some deep breaths, or sometimes they just wait for it to pass.

For some kids, this shift is really hard and they need help. They’re anxious so much of the time, and their independent coping systems may not work quite as well. And so they continue to rely on the attachment system by being near parents, listening to their voices, and relying on them to make things better. It’s not that these kids don’t have an independent coping system; it just needs some practice. It’s like someone who is born with a weakness in their legs and falls a lot and so prefers not to walk around too much. What they really need is the opposite. It’s not that they don’t have legs. Or even that their legs can’t get stronger. It’s just harder for them and comes less naturally. We want to encourage someone like that to walk every day! By not walking, their legs will just get weaker and weaker. But if they start practicing, they can catch up. They may never run a marathon, but they can be just as capable as everyone else. And who knows, with enough practice, maybe they will run that marathon. We don’t want to carry them around or push them in a wheelchair. That doesn’t help; it keeps them weak. We want to encourage them to walk, and when they ask for that wheelchair, we want to stay firm and say, “No way!” When they think they can’t do it, we want to encourage them, show them we believe in them, and, above all, keep them walking. Even if they think we’re being mean, we know we’re doing the right thing. An anxious child has an independent coping system just like all the other kids. It’s just a little weaker and needs extra practice. So when we accommodate, it’s a little bit like giving them that wheelchair. It helps them to feel good but keeps them weak. I want to help you do the opposite. Show them that you believe in them. Let them know that you care and that you know how hard it is. Encourage them to find that strength that’s in there, and soon they’ll be getting back to calm all on their own.

The Avoidance Trap

Everybody wants to avoid the things that make them anxious. Well, sometimes we enjoy things that make us anxious like scary rides and horror movies. But we only enjoy them when we know we’re actually safe. When we’re sure things are OK it can be fun to be a little scared. But if a roller coaster breaks down, nobody’s having fun anymore. Everyone wants off. Because real anxiety, actually feeing unsafe and not knowing if things will turn out OK, is not fun, and we want to avoid it. Whether it’s situations that scare us or just feelings of threat and insecurity, being anxious will make us want to avoid and feel safe again. But avoidance is also a trap. If we avoid things, we stay scared of them. We don’t get used to them or realize they’re actually safe. In fact, we become even more scared every time we avoid them. It’s like we’re telling ourselves: “See I avoided that, it must really be dangerous just like I thought. And I’m only safe now because I avoided it, (p. 63) otherwise it would have been a disaster.” It’s easy to keep believing that when we continue to avoid. As we avoid, we get more anxious, and as we get more anxious, we avoid more and more. We learn to take extra-special steps to make sure we don’t even come near the thing we’re avoiding. We become super avoiders. And, of course, we pay a steep price in all the things we can’t do. But it feels like it’s worth it to be safe! We also start relying on our parents for help in avoiding. All those little and big ways that parents can help a child avoid the things that make them anxious: doing things for them, checking to eliminate doubt, reassuring them, clearing a path like a minesweeper removing anxiety mines so that nothing sets them off. Those can all feel like help, but they’re keeping that avoidance trap going. When our parents are our minesweepers, we don’t really get a chance to discover that those weren’t really mines at all—that we wouldn’t have exploded, we would have just been uncomfortable for a while. We don’t get used to all those things our parents are helping us not do. In fact, with help from family we can really be amazing avoiders, but we’re not getting any less anxious because we’re stuck in the avoidance trap.

Actions Speak Louder Than Words

The therapist can introduce this concept by posing the question: What would you want most for your Clara to know? This kid, who is so scared of embarrassing herself and of what others will think about her. If you could tell her one thing, and she would really accept it, just know deep down that it’s definitely true, what would you tell her? That she’s great just as she is? That it doesn’t matter what other people think? That she’s not going to humiliate herself in front of everyone? Maybe that people aren’t quite as obsessed with thinking about her and judging her as she thinks? Wouldn’t it be great if you could get her to realize even one of those things? If you had the power to do that? Sounds amazing! Certainly, you wouldn’t want to tell her the opposite. That’s obvious. I’m sure you don’t say to her, “Listen Clara, before you go into class you ought to know there’s a good chance you’re going to really mess up, and I bet everyone will laugh at you and talk about it for ages.” Who would say that? Or “Hey, Clara, you know that school trip you’ve been worrying about? Well, it turns out you were right. All the other kids are just waiting to pounce on you because you speak too fast. Or too slow. Or tell stupid jokes. Basically, nobody really likes you anymore.” Or even “Oh, Clara? Remember how you told me you thought you would die if everyone saw you blushing because it’s just too humiliating? Well . . . yup. You might not actually die, but you’ll never be the same again. You’ll just feel worse and worse and that terrible awful feeling will never go away.” Of course, you’d never say any of those horrible things! I know you wish you could show her the opposite. That her thoughts are irrational, and exaggerated, and absurd. But Clara is not just listening to your words. In fact, your words don’t actually make that big of a difference. If they did, well, you’d already have told her how to feel and things would be fine. Clara is listening to what you do. When your words say, “The trip will be fine,” but your actions say, “I’m not (p. 64) sure you can do this,” she only hears the uncertainty and doubt. And when your words say, “Nobody will laugh at you,” but you plead with her teacher never to call on her, your actions are saying, “You can’t handle this.” When you leave places early because she’s getting uncomfortable you can tell her the whole ride home that she could have stayed, but she’s already listened to your action saying, “I know you actually couldn’t.”

Each of these examples illustrates a different approach to the topic of family accommodation, and many therapists have their own variations or preferred way of introducing the topic with parents. What all good approaches will share is an empathy for the parents’ dilemma, a lack of judgement for accommodations that have been provided in the past, and a relatable rationale for reducing accommodation as a means of helping their anxious child.

Talking with Children

Work with parents can be done independently of child therapy or alongside and coordinated with child therapy. Some therapists prefer not to work with the child and parents at the same time, while others feel that working with both allows for synergy and integration. When there is opportunity to do so, it can be useful to explain to children the rationale for focusing on the family accommodation. The topic can be broached either in a joint session with the child and parents present or, in cases where clinical judgement suggests it would be preferable, in sessions with the child alone. The goal here is not necessarily to convince the child that they will be better off if the accommodation is reduced. This would be a good outcome, and, in fact, many children already know or sense this, but it is not critical that they be persuaded or that they acknowledge it if they are convinced. Rather, the goals are to create a framework within which the child can understand the actions the parents will take; to provide support for the parents by demonstrating that they will be acting on expert advice (and sometimes to allow the child to direct anger or blame toward the therapist rather than the parents); to open up communication and discussion in the family of a topic that may have been avoided previously; to clarify that the changes are being made with the child’s well-being in mind and not only for parents’ sake; to acknowledge that the process can be difficult for the child and that this is not taken lightly; to invite feedback from the child that can help to shape treatment plans; and to express confidence that the child is able to cope and will ultimately get better as a result of the parent’ actions.

It sounds like your anxiety has been really bad recently, and you’ve been really brave coping with it all this time. I’m glad you’re here now so we can help. We’ve been talking about some of the things we can do together to help you get better, and I think you’re going to do great! I’m also going to be talking to your mom and dad about some ways that they can help you as well. They love you a lot and really want to do everything they can. I’m going to think with them about (p. 65) which things they’re doing right and which things they should probably be doing differently. That’s always how it works: Kids come here to learn, and parents come here to learn as well. For example, we talked about how because television characters make you really uncomfortable, your parents have stopped letting your sister watch her shows. That’s one we need to think about. Of course, it makes sense that you prefer she not see something that scares you, and your parents want to help you with that. But sometimes the things we do to help actually don’t really help. Can you think of something you used to be scared of and now you’re not anymore? I bet that’s because you kept on doing it, or facing it. What would have happened if your parents had said, “OK, that’s over now, no more of that ever again”? I bet you’d still be pretty scared. So, we’ll think really hard about this and try to come up with some things that are actually more helpful. I guarantee we won’t be trying to surprise you. In fact, let me say that to your parents right here in front of you: No surprises! We’re going to let you know the plan every step of the way. I can’t promise that you’ll like all of my suggestions, but I can promise that they won’t hurt you. And if anything that I recommend makes you too uncomfortable or makes you mad at me, you can always tell me that. I won’t get mad back! I like it when kids tell me how they really feel, so don’t hold back. We may even make some changes based on what you say. Maybe not always, but nobody’s perfect, I can make mistakes, and you might have some really good ideas I’ll want to use.

Mapping Accommodation

Even after good and thorough evaluation, there are likely to be accommodations that have not been discussed. As the therapist comes closer to choosing an accommodation to modify (discussed next), it is better to have more information about the current accommodations. Mapping out the accommodation can take an entire session (or even more) and is followed by parents monitoring their behavior for such accommodations over the course of one week. This time is crucial as it yields valuable information and helps develop better treatment targets.

A straightforward method for mapping accommodation is to review a typical day in the child’s and parents’ life. Starting as early as the parent wakes up, the therapist can ask the parents to describe in detail what they consider a typical day and to note any changes they have made to their behavior due to their child’s anxiety. The review can focus particularly on the accommodation “hot spots” described in Chapter 5, such as mealtime, showers, bedtime, transitions, separations, and homework. The therapist can ask questions when a behavior or pattern described sound as though they may reflect family accommodation. For example:

therapist: Let’s go through what a day looks like for you and Theo. Start from the moment you wake up and try to describe for me how things go throughout the day. I know not every day is the same but think about a typical day, and if there are accommodations you only do on some days, let me know about (p. 66) those as well. I’d like each of you to tell me the things you do, which, of course, are going to be different, as well as the things Theo does.

vivienne: Well, I get up around 5:45 and I get dressed. I’ll usually wake Theo around six.

therapist: Is it hard to wake Theo up?

vivienne: Not at all. He’s always been a morning person. Sometimes he’s already awake when I go in, but usually I just touch his head or call him softly and he’ll be up.

therapist: OK, thanks. I envy you! Six is pretty early. Does he need to get up at that time to make the school bus?

enrique: Not really, he just . . .

vivienne: I was answering him, you know. Anyway, it’s true. He doesn’t really need to be up at six. But he likes to take his time in the morning. He’s very particular about his clothes and his hair.

enrique: [Mumbles]

vivienne: Enrique, please! He’s particular. I used to wake him at 6:30, but he would spend so much time choosing his clothes and asking me if he looked bad that it would make him late. For a while I was picking out his clothes for him, to try to make it easier. And because I have great taste [laughs].

therapist: But now he chooses by himself?

vivienne: Yes, he told me he prefers it that way, but he still asks me many times if he’s making a mistake with one piece of clothing or another. He also brushes his teeth for a long time. He says he doesn’t want people to think he has bad breath. Who ever heard of a teenage boy who worries so much about his teeth?

therapist: It sounds like that all takes a lot of time. Go on.

vivienne: Yes, so eventually I started waking him up earlier so he has time for all his clothes and his tooth brushing and his questions, and everything.

In this snippet of dialogue between a therapist and two parents, going through the day has immediately yielded valuable information. Vivienne is accommodating her son Theo by waking him at least half an hour early each day because he is anxious about his appearance and his odor. She also answers many questions about his clothing and, in the past, accommodated by selecting the clothing for him.

The conversation is also beginning to hint at some additional information that may require further exploration and attention if the parent work is to be successful. There appears to be some tension between the two parents, due to their differing attitudes about Theo’s behavior. Vivienne normalizes the behavior, labeling Theo as “particular,” and seems to be downplaying its importance and the extent of accommodation. Enrique, though he does not clearly express his views in this brief interaction, gives the impression that he does not quite see things the same way. Disagreement between parents of anxious children, with regards to the child’s symptoms and the parental response, is common and can pose a challenge to effective parent work. Chapter 9 offers suggestions for addressing parental discord and improving collaboration in addressing family accommodation.

(p. 67) In mapping the accommodation, the therapist may wish to ask parents to also describe a weekend day in addition to a school day as these can be very different. Different amounts of time spent together, different activities, and different goals and objectives for the child can all contribute to a very different picture of family accommodation as well.

Finally, the accommodation map should include accommodation by siblings, teachers, or others in the child’s circle who may be providing accommodation.

The therapist can give the parents the Accommodation Monitoring Chart and ask them to monitor their behavior over the course of the week, noticing and noting down when they are providing accommodation. Parents can note the frequency and circumstances of the accommodations identified in the mapping out process and can also make note of other accommodations that are either new or were not identified previously.

Choosing Where to Focus

Most family’s accommodation map will include several, and often many, different accommodations. It won’t be possible for parents to change their behavior in all these domains at once, nor is it likely to be beneficial to the child for the parents to completely modify their behavior in all areas all at once. The therapist and the parent will therefore have to choose where to focus their efforts, which is not a trivial choice.

One important consideration is the parents’ preference and motivation. Parents are more likely to persist with a target that they identified as important—both because they clearly think this is a valuable and important target and because they can feel more ownership and agency around a plan that is based on their preference. Of course, parents may not agree with each other and can have different preferences. Vivienne, for example, may not feel that waking Theo up early is an important accommodation, while Enrique may believe that it is. The therapist can take both perspectives into account and, even while steering toward one or the other’s suggestion, can acknowledge the validity of the different thoughts. Having both parents on board will make each of them more likely to persist.

Additional considerations include the frequency of the accommodation, the extent and severity of interference yielded, the child’s attitudes and responses when not accommodated, and the potential for deterioration in the child or family functioning upon encountering difficulties with the plan.

Frequent accommodations that occur multiple times per week or per day are preferable because they afford many opportunities for the parents to practice and for the child to become accustomed to the new parental behavior. An accommodation that happens only rarely, even when important in the eyes of the parents, may not occur at all between sessions, making it more difficult to implement a practical plan. A rare accommodation could be selected as an additional target alongside a more frequent one (see Box 6.1). (p. 68)

Accommodations that cause significant interference for the parents or other family members are generally preferable for two reasons. First, parents are likely to be motivated to accomplish meaningful change and thus may adhere more resolutely and consistently to the treatment plan. Second, improvement in these accommodations will likely reflect meaningful improvement in the family life, in line with the interference the accommodation was causing.

The potential for deterioration in the child’s functioning, when not accommodated, should also be considered carefully. For example, if Vivienne were to not wake up Theo early, or if she stopped answering repeated questions about his clothes and looks in the morning, it may become more likely that Theo would be late for school. Or that one or both of the parents would be late for work due to having to remain with him until he felt able to leave for school. Reducing accommodations around bedtime carry the potential for disrupted sleep, both for the anxious child and for others in the home. Reducing accommodations around mealtimes can lead temporarily to diminished eating. The implication of these risks is not that these targets should not be addressed. Every accommodation probably has some potential to impact the child or family functioning in one way or another. Rather, the implication is that these possibilities should be considered, parents should be prepared for them, and the plan that is devised should include contingencies for how parents will respond in the event that they occur, as discussed in the section on devising accommodation reduction plans.

The child’s input can also be taken into account in selecting an area of focus. A child may be less resistant to a plan that has taken their preferences into account. And even when their wishes are not ultimately the deciding factor, listening to their view respectfully, and acknowledging their stake in the matter can facilitate an easier process. It may be preferable to start by targeting an accommodation that the child feels willing to take on, even when other accommodations would usually be the first choice. Additional targets can follow, and beginning the process in a collaborative manner is valuable.