Anne Bodmer Lutz, B.S.N., M.D.

Anxiety is a common occurrence for children and adolescents with lifetime prevalence rates ranging from 2.6% to 20%. Children and adolescents coping with anxiety may experience lower achievement, difficulties with social and emotional functioning, depression, and substance use disorders. There are many examples of how anxiety presents with youth: school refusal, anxiety when transitioning from middle school to HS, from HS to college, and from college to becoming a working adult, fears of separation and illness of loved ones, somatic symptoms such as headaches, stomachaches, discomfort in social situations, intense fear that occurs unexpectedly, panic attacks, obsessions and compulsions.

Solution-Focused Brief Therapy is an effective treatment approach for youth managing anxiety. The goal of this article is to demonstrate how to apply solution-focused techniques with youth coping with anxiety and how these strategies can provide an additive dimension to the problem-focused treatments typically utilized.

Traditional problem-focused Cognitive Behavioral Treatment (CBT) of anxiety addresses deficits in coping with both children and parents such as avoidance, distraction, rumination, self-blame and catastrophizing. There is a focus on education about anxiety, threat overestimation and the use of fear hierarchies, cognitive restructuring, problem-solving, and contingency management. Parental anxiety, “over-controlling” parenting behaviors and parental accommodation are additional areas of focus. The classic CBT triangle focuses on the interaction of thoughts, feelings, and behaviors.

Some Specific Solution-Focused Approaches in the treatment of Anxious Youth

Commencing with Competencies: Commencing with strengths is especially important for youth coping with anxiety. Activating resources from the onset of the conversation by exploring what they enjoy and are good at creates a narrative in which the client views themselves as more than their presenting problem. For example, one client who presented with severe anxiety and was refusing to go to school talked about her love for her animals and biking. She was unique in her ability to bond with her snake, and in her skill riding dirt bikes with her older brother. Taking time to explore these “problem-free” areas was essential and not a waste of time, exemplifying positive behaviors (actions) in which she was able to courageously approach situations that are typically challenging for many others.

Complimenting: Children and adolescents experiencing anxiety frequently present with significant distress. Children in distress often generate anxiety and concern on the part of their parents. Parents try their best to support their child, but this often presents as reassurance, accommodations and frequent texting and phone calls. It is important to compliment parents on their efforts to remain calm, demonstrate empathy, maintain consistent limits and get their child to school despite the child’s level of discomfort. Asking about the specific details of how they managed to get their child on the bus, to school, refrain from texting them, while at the same time successfully managing their anxiety helps strengthen parental confidence and competence in supporting their child. These kinds of compliments can impart much-needed energy and stamina to both youth and families, enabling them to persevere when they are feeling exhausted and overwhelmed.

For You Statements: Integrating the words “for you” into responses to clients is a language technique that serves to quickly and easily communicate empathy. “For you” statements can be used in several different ways, helping to build emotional agreement within the conversation, while providing validation and acknowledgment of the client’s situation and feelings. Clients and families who are coping with anxiety and panic are experiencing significant distress, and this is critical to acknowledge. Some examples of “For You” statements include how scary and frightening it must be “for you” to see your child struggling with anxiety. For the adolescent, this may take the form of acknowledging how difficult it must be “for you” to be having these experiences, how frustrating it must be “for you” to be forced to go to school, and how uncomfortable it is to be experiencing such distress. “For you” statements can also be used to acknowledge positive client experiences, such as how exciting it must “for them” to be making progress towards their goals, to make it to school and experience academic and social successes. Positive “for you” statements reinforce with clients that what they are doing that is working for them.

Positive Differences/Exceptions: Listening for and discovering positive differences when youth are having some measure of success is crucial. These may include times when they can approach and “do” things that are challenging. Acknowledging and appreciating how children managed to get to school even 1 out of 5 days, or even part of a day, made a decision even if seemingly small, slept in their own bed for part of the night, talked to people even if for only brief moments, tried something new, no matter how small, tolerated uncomfortable feelings even if for a short-lived amount of time. While these moments could easily go unnoticed, they are the very times that are crucial to amplify. It is especially important to explore whether these actions constitute differences for the parents and children. If so, how were they different? Were they helpful for them? How were they helpful? How did they do it? How else? (Notice how the use of the past tense (how “did” they do it) highlights accomplishments clients has already had success with and further builds their sense of self-efficacy.)

Best Hopes: Inviting clients to talk about their “best hopes” for treatment and asking how you can be most helpful for them so that meeting with them is worthwhile maintains the focus on what the client wants, their desired outcome. For example, “to not feel so stressed,” ” feel comfortable going to school,” ” be able to sleep in their own bed,” ” be better able to make decisions,” ” not have panic attacks,” ” make more friends,” ” not pull at their hair.” The list is endless and unique just as clients are each unique.

After eliciting a client’s best hopes, the question then becomes how to help clients achieve their goals. What do they need to make their best hopes come to fruition? Moving from best hopes to solutions takes actions (doing). “Doing” means explicitly helping clients discover outward actions such as trying to speak up a few more times in class, attempting to talk to someone new, or staying in their own bed a little longer. These “outwardly doing” actions are best discovered from the client and what they have already tried and know about themselves. The word “do” can also include what clients are thinking, what they are saying inwardly to themselves, and how they are managing uncomfortable feelings. It can also include a conversation about what their VIPs have noticed they have done and what they know about them that has already helped them achieve their goal.

In solution-focused therapy, most of the “actions” come from the client as well as their social context, those most important in their lives. Discovering client based “actions” and solutions does not mean a clinician refrains from offering possible action steps that they think may be helpful for the client. Rather these suggestions come much later in the conversation, and only after there has been detailed questions about what the client has already done and knows they need to do to meet their goals.

Ericksonian idea epitomized by his adage “The patient knows the solution to his problem, he only does not know that he knows”.

Solution-Focused Triangle Approach to the Treatment of Anxiety

The following is an explanation of how I have adapted a Solution-Focused Triangle approach for the treatment of anxiety. I begin by exploring the client’s best hopes for today’s session. If clients use the word “anxious,” I make sure to explore what they mean by this word. It can mean many different things to people and taking the time to understand what it means for them is important when building a shared dialect. Exploring what they have tried to manage their anxiety suggests they have been trying their best to deal with their difficulties.

Providing education about how anxiety is a common occurrence for all humans (and mammals) and normalizing the fight or flight response helps youth feel they are “not alone” in their distress, and how anxiety “worry” can be a protective mechanism.

Use of Small Index Cards:
I begin by drawing a triangle on one side of a small index card and a scale from 1-10 on the opposite side, where ten is they are managing their anxiety in a satisfactory “good enough” way, and 1 is the opposite. The front side of the index card addresses the three core focal points when successfully managing anxiety:

1: What they are “doing” to approach challenging situations
2. What they are doing to manage and tolerate uncomfortable feelings while still approaching challenging situations
3. What helpful self-talk and helpful questions do they ask themselves to assist in approaching their unique, challenging situations?

The back of the card has the scale from 1-10. I also use scaling to create courage hierarchies (instead of fear hierarchies). I find that children are more inclined to be able to answer “Are you up for the challenge of making a courage hierarchy? We then list from 1-10 courage challenges with one being the easiest and ten the most challenging. I ask them where they are at now. If it is higher than a 1, we explore how they managed to overcome the challenge, how ready they are to try the next challenge (from 1-10) and how confident they are that they can try their best to overcome this challenge.

Following our discussion of discovered hopes and skills, I give the card to the client and also make a copy for my chart. Often clients will put the card in a special place and bring it back to the next session on their initiative.

I provide clients the analogy of how airline pilots face an emergency. Pilots don’t “wing it,” but instead refer to their emergency checklists. When people feel they are in danger, their amygdala gets shaken up. And when your amygdala is shaken up it is challenging to think clearly. Having this index card available assists clients in remembering what to do and check on when they are having “psychic emergencies.”

The importance of sleep: I also make sure to ask about sleep.

  • How satisfied are you with your sleep from 1-10, where ten is the best?
  • What is good enough?
  • When was it last good enough?
  • What have they tried to do to help them sleep?

Sometimes simple things can be very effective in helping improve sleep such as getting on a regular sleep schedule, turning off electronics an hour before bedtime, limiting caffeine, to name a few. The important point is to assess sleep satisfaction. Without good sleep, it is difficult to calm the amygdala and manage anxiety.

The Solution-Focused Triangle Approach for Treatment of Anxiety

The Solution-Focused Triangle Approach for Treatment of Anxiety

OVERALL GOAL NEGOTIATION (BEST HOPES)

  • What are your best hopes for today?
  • What are your best hopes that would tell you that you are managing your anxiety in a way that is “good enough” and “satisfactory” for you?
  • What will you be doing when you are managing “good enough”?
  • What else will you be doing?
  • What will your VIPS notice you are doing? What else will they notice you are doing?
  • What have you tried to do to manage your anxiety?
  • What has been most helpful?

DOING (APPROACHING)
Supposing we made a list of challenges to approach that would tell you that you are managing your anxiety what would you be doing?

What else would you be doing? What else?

(i.e.) Going to school, getting my homework done, talking to teachers, staying in class, calling people on the phone, trying a new activity, studying for tests, starting on homework sooner, writing in my agenda, talking to one friend at school, managing unexpected situations.

What would others notice you are doing that tells them you are managing your anxiety?

What else? What else?

Scaling Approaching Challenging Situations:

  • Supposing ten is you are satisfied with how well you have approached situations that are challenging for you and one is the opposite, where would you say you are now?
  • What is a good enough number?
  • What is the highest number it has been?
  • What keeps it from being lower?
  • What else?
  • What number would your VIPS give you regarding your ability to approach situations that are challenging for you?
  • What would be the next step that would tell you that number went up by one point?

HELPFUL SELF-TALK AND HELPFUL QUESTIONS THAT ASSIST IN YOU APPROACHING/”DOING” CHALLENGES

What are your best hopes that would tell you that you are managing your anxiety? What do you want?
What else?

  • (i.e.) I want to be able to graduate to the next grade
  • I want to spend time with friends
  • I want to be successful
  • I want to go to school and enjoy it
  • What questions could you ask yourself that you think would be helpful for you in approaching your challenges?
  • Is it going to help me to stay at home?
  • What have I done when I’ve made it to school before?
  • In what ways have I successfully managed my OCD symptoms?
  • What has helped me calm down?
  • What would I say to my friends in this situation?

MANAGING/TOLERATING UNCOMFORTABLE FEELINGS

What have I done to manage uncomfortable feelings?
What else? What else?

(i.e.) Take a walk, acknowledge feelings are uncomfortable, but not dangerous, practice deep breathing and smiling, practice breathing and counting, remind myself that uncomfortable feelings usually last 10 minutes and then pass and what have I done to tolerate them before?

SCALING THE TRIANGLE

For each of the points on the triangle I scale where they are:

DOING/APPROACHING:

  • How satisfied are you with your ability to approach challenging situations where ten is the best and one is the opposite?
  • What is a good enough number?
  • What keeps it from being lower? What else?
  • What number would your VIPS say you are at? What number would they say would be “good enough”?
  • What would you be doing when it goes up by one point? What else?
  • How confident are you that you can try your best to raise it by one point?

HELPFUL SELF-TALK AND QUESTION:

  • How satisfied are you with your ability to ask yourself helpful questions and tell yourself helpful statements that will encourage you to approach the challenging situations we discussed?
  • What is a good enough number?
  • What’s the highest it has been?
  • What number would your VIPS give you?
  • What would you be doing when that number goes up by one point?
  • How confident are you that you can try to raise that number by one point from 1-10?

MANAGING UNCOMFORTABLE FEELINGS:

  • How satisfied are you with your ability to manage your uncomfortable feelings so that you can approach the challenges you hope to achieve?
  • What is a good enough number?
  • What is the highest it has been?
  • What keeps it from being lower? What else?
  • How well would your VIPS say you are managing your uncomfortable feelings so that you can approach the challenges you hope to achieve from 1-10?