Episode Transcript
[00:00:16] Speaker A: Hello. Thanks for joining us. It is such a pleasure to be here with Briana Myers, licensed clinical social worker, therapist and supervisor at N Stride Health.
Thanks for joining us, Brianna.
[00:00:30] Speaker B: Thank you, Anna. I'm excited to be here.
[00:00:32] Speaker A: Yeah. You know, when we were chatting a little bit, it was so neat to learn more about the unique approaches of using certain therapies for anxiety in children and how really the virtual setting can be a benefit.
I'm curious to learn a little more about this work that you do and how your unique approaches are helpful in ways when maybe traditional talk therapy in the office is not working.
[00:01:03] Speaker B: Yeah, absolutely. So I can start just giving a little bit of a blurb about In Stride. So In Stride is a completely virtual specialty outpatient program for youth and young adults who have anxiety. And October, um, we typically are treating kids age 7, roughly to 22, but there's some flexibility in those ages. And I think that question that you just asked about, how does virtual treatment sort of work for these kids who have pretty severe anxiety and OCD work? Is the exact question that I had when I was first interviewing at In Stride. I was like, exposure therapy. How can that work in a virtual setting and be effective? And I think one of the things that has been most special for me to learn is that the. The virtual model really puts kids in the spaces where they're struggling. A lot of our kids come in with school avoidance as a challenge. You know, agoraphobia, struggling to leave the house, you know, separation concerns where they're not able to go out to the community and, you know, spend time with their friends and do all the things that kids love to do. And by being able to meet with them, virtually, first and foremost, we're able to meet a kid where they're at. Right. Sometimes these kids are not able to go into a physical office and meet with a therapist. So we're really able to meet them where they're at, just in terms of the engagement perspective. But also when they're doing all of these really hard exposures out in the community, I'm right there with them. Even though I'm in New York City and my patient might be, you know, in Massachusetts or another state, I'm able to be with them on the phone, you know, cheering them through these exposures. And I think a lot of kids and families have found that to be very, very impactful and really moving the needle for. For them.
[00:02:53] Speaker A: That is so, so interesting to think about, you know, how I know a little bit about exposure and response prevention therapy. And I think it is just fascinating. And in a moment, I want to ask you kind of some of the basics of it, just to fill in the audience and those who may not be familiar with it. But I know certainly there is a term called white knuckling. When we think about exposure and response prevention, where, you know, we, we're trying to kind of help people adjust to stressors in a way that they, they. It doesn't overwhelm them and they don't go into shutdown mode where it like, reinforces the anxiety.
And I was just thinking about how, you know, a lot of times if someone is struggling with a horophobia or if there's something just about, you know, feeling unsafe in certain situations, going into a physical office or whatnot, like maybe they may already be white knuckling when they're there. Right? There may be like a raised level of anxiety.
So being able to meet someone in their safe space or being able to meet them in the place where they're feeling challenged, like school, I could see it being really beneficial and kind of like really addressing real life situations that, that they're trying to overcome, if that's on the treatment plan.
But with that said, could you give us a little bit of an understanding? Because, I mean, certainly most therapists, all therapists, right, have worked with anxiety. We know that that's like often the bread and butter of why people are coming in. And we've, a lot of us know about, see CBT and using mindfulness skills, even self compassion or other techniques. What makes ERP stand apart and why is it so important to use instead of some of these other tools or alongside these other tools when we're dealing with specific types of anxiety?
[00:04:39] Speaker B: Yeah, absolutely. I really think about, you know, CBT and ERP sort of existing side by side. I think a lot of folks come into our program having done CBT before and really focusing on the cognitive elements, so being able to identify, you know, their negative thoughts, being able to reframe those negative thoughts, and that certainly is helpful for sure. But when I think about erp, I really think about the big B of cbt. So focusing on that behavior change.
I think one of the key elements of both anxiety and OCD is avoidance.
And so what ERP helps patients do is push back against that avoidance a little bit.
So in my most, like, simple terms, I think about ERP as practicing the things that scare you on purpose with intention.
So essentially we help kids to build a fear and avoidance hierarchy. What are all of the different tasks that they might be Avoiding right now that they find really challenging. And we practice approaching each of those tasks in a really slow and sort of graduated way. And by doing that, kids start to learn that number one, maybe the thing that I was really afraid of is not that scary after all.
Or they start to learn that even if it was really scary. Right. A lot of these tests are really scary for kids too. They still learn that I have more capacity than I thought that I had before. I have more of an ability to you face my fears that I thought that I had before. And that alone is so powerful for these kids to learn and understand.
[00:06:18] Speaker A: Absolutely.
[00:06:19] Speaker B: Yeah.
[00:06:19] Speaker A: You know, I've noticed working with kids and anxiety and adults. Right.
We can only go so far with just talking about it, you know, and it's easier to talk about it or make plans when you're calm. But the second that that anxiety kicks in and that fight or flight reaction kicks in, the second there's this like strong survival mechanism that that kind of pushes back on any kind of the parts of ourselves that have, you know, planned ahead of time of how we may want to cope. And we quickly go into often like avoidance as a way to, to cope.
But I know, you know, research and shows that like actually sometimes that, that avoidance, while, while, you know, at some points it can actually, um, help us survive in difficult situations, it actually can in other situations really exacerbate the anxiety because of that loop. Right. Of, of kind of our belief cycle that avoiding it is actually what makes the anxiety go away. So we, we keep seeking that avoidance. Um, so, so tell me a little bit about like if you were going to work with a child who, let's say, had school avoidance, what are some common things that you see like have been in terms of ways in which traditional therapy may approach that or like before the child gets to you, and ways that you may see the parents trying to cope with it, the pediatrician trying to cope with it, school counselors versus some of the shifts that are made once they start working with your program and using ERP virtually.
[00:07:53] Speaker B: Yeah, absolutely. I think from a school perspective, one of the things that I've noticed being in this role and working really closely alongside, you know, school counselors, school social workers and caregivers, is that a lot of our go to strategies within schools tend to be avoidance based.
So if a child is struggling with anxiety in the school setting, some of the items that might be on someone's IEP or a 504 plan are really rooted in avoidance. And so when they come into our program that's one of the first things that we want to shift. We want kids to understand that school is important to you, school is important to us. We understand that your education is important and we want to do everything in our power to get you back in that school setting. We know that avoidance is going to reinforce our anxiety and ocd. So we're going to start slow by getting you back into that school setting. Slowly but surely.
Other things that we see in terms of school avoidance are challenges in the mornings when with caregivers, parents are really struggling to get their kids out of bed, into the car, onto the school bus to get to school in the morning. And I think that's another really big benefit of in stride being a virtual program is we can really work within the full system. I'm able to have these virtual meetings with kids, you know, be there with them during the school day when they're really struggling with getting in. But I'm also able to have meetings with parents and understand what does that morning routine look like, what are the things that we can shift about how we approach the morning time, how, how we approach, you know, our child, expressing anxiety too around school to start to shift some things for people. And then of course we have the school aspect where we're able to, to work with providers in the school environment.
[00:09:51] Speaker A: So that's really interesting. So you're going to the idea of supporting parents, supporting the school.
I'm curious for therapists, what, like, what does that look like if someone is in long term care and not just if they choose in stride, but if they're going to use any kind of supportive service outside of their work as a therapist, what should they be kind of looking for in terms of collaboration or the way in which to work erpn? If they are perhaps like have a strong foundation with the child, have good rapport, really want to continue on their relationship, but feel like they're bumping up kind of a area in, in training in which they're recognizing that ERP could be really important, but it's not something that, that they're trained in and perhaps like realistically don't have the time to get the training and the child in the time that the child needs.
What would you suggest a therapist kind of look for when they're, when they're looking at potentially adding or suggesting that ERP be added in so that, you know, they stay in the loop?
[00:11:03] Speaker B: Yeah, absolutely.
I think that one of the reasons why I find most kids are coming into our program is they have been in long Term care, but they're still finding themselves to be stuck. So I think when a therapist is looking at, you know, a kid that they've been working with for, for a while now, they have good rapport, the kid is motivated, but the progress is not quite at the level that you would expect.
That might be a good indicator to me that there could be a shift in approach that could be beneficial for that child, like bringing in ERP principals. And I do think that training, you know, more specific training in ERP is really important, but I think a lot of the principles of ERP are things that clinicians of all kinds could really fold into their work already.
So, again, one of the main pieces of ERP is thinking about approaching instead of avoiding. So when you're noticing kids talk about avoidance, or if you're thinking about, I think there might be some avoidance here, either physically or even emotionally, their ability to talk about the things that feel challenging, think about the things that feel challenging, experience particular emotions. I think those are things that as a provider, you could be helping them practice already before they even get into a more formalized ERP focused program or with a more ERP focused provider.
[00:12:35] Speaker A: So building up some skills to work on tolerance.
Interesting. So the, the approach of, you know, and often you see parents on one side or the other, and oftentimes they. They do, they do the opposite to hopefully balance it out, but it ends up just causing a lot of chaos where, like, one parent will be the one who's maybe coddling a little more or, like, it's okay, I don't, you know, you can take a break, you know, encouraging the avoidance, maybe. And then maybe you have the other side where you've got someone who's kind of like, just like, wants to throw them in the pool in the deep end. Right. That approach of, like, let's just push.
Tell me a little bit about that dynamic and what ERP would say about that, or how ERP might approach that, or an ERP perspective might approach that.
[00:13:22] Speaker B: Yeah, I feel like that comes up so often, Right. And when I'm talking to parents, I talk about that sort of quote, unquote, good cop, bad cop dynamic that often exists with caregivers.
And one of the first things that I try to do is really validate parents because nobody is coming in wanting to do something that's going to hurt their child, make their child's anxiety or OCD worse. Everyone's doing the best they can with the knowledge that they have to try to support their child. So that's the first thing that I try to do, I think parents have a lot on their plate, a lot of pressures on them, and it can be tough when somebody comes in and says, hey, maybe let's try a different sort of, sort of perspective.
But what I try to encourage parents to do is really marry those two ideas together. It is important to validate your child's anxiety and the experience that they're having, the fear that they might be feeling in a particular moment. And the other piece is helpful too, of let's hold this emotion and still continue to take a brave step forward.
So we talk about this idea of empathizing and encouraging. I'm going to validate this emotion. Yeah, I understand that this is really hard right now. I see that you're really scared right now. And follow that up with Ann. What's that one brave step that we can take in the moment?
Maybe if this is a school of ordinance case, it's like, okay, can we get our shoes on right now? Can we, can we start to get dressed? Can we sit down and eat breakfast? Can we just take that one step out the door?
And then often when parents sort of like pull back and focus on that tiny step, we start to build momentum. Right. That one step turns into another step and another step and another step until we're able to get into the school building and get into the classroom.
So that's the main approach that I try to share to parents. Let's work on the empathizing piece and make sure that we're following it up with a concrete step to push back against that avoidance.
[00:15:27] Speaker A: Interesting.
So as a erp, virtual, you know, practice, how, how might, how do you show up, you know, in session in terms of like, what, what might it look like? It sounds like you, you might even schedule. If there's school avoidance, you might schedule a session in the morning time before school, Is that correct?
[00:15:47] Speaker B: Yes. So we are able to be with kids during the school day, which I find so valuable. We're able to collaborate with school, school counselors to have sessions during the day, you know, most of the time in their offices or some other sort of private space.
But in terms of what our sessions sort of look like on a day to day, we typically start with a lot of psychoeducation about anxiety, ocd, how those disorders work, spending time working through the sort of classic CBT skills. So helping kids to understand emotions, identify, communicate emotions, understand their thoughts, reframe thoughts, and then we spend a good chunk of our time in session working on the actual exposure piece Whether that looks like doing an exposure just together in session. So maybe that is working through an imaginal exposure or something else that can be done in their home environment or at times we also set up community based exposures.
So that might look like for a kid with social anxiety, going out to the mall, right. And asking a question of a stranger. Or for a kid with agoraphobia, maybe the exposure is just taking a walk around the neighborhood, you know, showing me the things outside in your environment. So we're really able to be flexible and again get those kids into the specific settings that tend to bring up their anxiety the most.
[00:17:18] Speaker A: That's interesting. It sounds like such a different model of care. I, I find myself like trying to bucket it into like a traditional, like what's not really it's not. I mean it is individual therapy, but a lot of times it sounds like these kids already have a therapist that they're continuing to work with. So it's not replacing that. It doesn't sound like it's an IOP or a php. They're not missing school. In fact, it's opposite certainly isn't residential. Like, tell me a little bit about how you see your model fitting in on the spectrum of different levels of care.
[00:17:52] Speaker B: Yeah, absolutely. We really have a sweet spot sort of right in the middle. It's not quite traditional once a week outpatient care, but we don't have the same intensity as a PHP or an inpatient model in stride. I would consider insrite to be an intensive program.
We have multiple sessions a week for the patients that come in.
So if a, if a child were to come into our program, they would meet with a therapist like myself for about 45 minutes each week in the beginning of treatment. And then each kid also has a exposure coach that they're assigned to as well. And so the exposure coach really is an extension of the therapist. They're helping to reinforce skills, helping to pract exposures with kids. So they have those meetings with their exposure coach twice a week. And then we also have in house psychiatry as well that people are receiving and then groups. So there's a lot of contact with different providers throughout the week.
And that's really intentional. We know that exposure is the sort of main mechanism of change that we're using. And we want kids to be practicing as much as possible.
Start doing exposures with me. They're doing exposures with their coach, they're doing exposures in group.
And then as someone goes through treatment, the cadence of appointments and the level of intensity starts to go down as they do more work outside of session as well.
So when somebody is first coming in, they're really setting the foundation, understanding exposures, getting a lot of direction from me or the coach. And then as they understand what does exposure look like, how can I identify exposure opportunities just in my own day to day life?
They become a little bit more independent and we're able to slowly but surely pull back that support until they're ready to really fly off on their own.
[00:19:55] Speaker A: So how long does treatment typically last?
[00:20:00] Speaker B: Yeah, that's a great question.
So most folks are with us for somewhere between 9 to 12 months on average.
So we really get to integrate ourselves into the lives of these kids. A lot of them are coming in.
I kind of find just anecdotally, a lot of kids come in at the beginning of the school year. That's a time when there's a lot of anxiety coming up. They had a really great summer where they're not really faced with a ton of stressors. And the school year comes and it's like, okay, this thing that was kind of running in the background before, it's like back full blown.
So typically I'm with a kid for the full school year, right, those like nine or 10 months.
But all of that is flexible. We want to be responsive to the progress that a child is making. So if somebody is coming in and really hitting the ground running, they might be able to graduate faster. And if somebody needs a little bit of extra time, they're able to spend some of that time with us. And then we also work really closely with outpatient providers to be able to have that warm handoff so they can carry that work forward even once they're done in our program.
[00:21:12] Speaker A: Okay, so. And in a situation where medication might be warranted, you know, how is that like, are you collaborating with outpatient psychiatrists if they already exist, or are you recommending certain. How does that work?
[00:21:28] Speaker B: Absolutely. Yep. So we do a lot of collaboration with outside psychiatrists. Like I was saying before, a lot of kids already come in with a good amount of therapy history. They might have an outpatient psychiatrist already. So the psychiatrist that we have on staff will be able to collaborate with those providers, provide consultation, just making sure that we have the right medication fit for that patient and keeping them updated on the things that we're seeing in terms of symptom, either increase or reduction.
But for those people who are not coming in with their own psychiatry services, they're able to utilize inside services pretty quickly into treatment. They'll do a Psychiatry intake, where they're able to, you know, ask all of the questions that they have of our. Our medical team. They're able to share a bit about their history and really get the ground running with medication, if that's something that parents are. Are interested in and kids are interested in.
[00:22:30] Speaker A: I've heard that it takes people an average of seven years to get properly diagnosed with ocd, that it's often misdiagnosed as generalized anxiety or something else.
And, you know, that is pretty shocking considering how debilitating the condition can be. And I'm curious about, like, why. Why is it so important to get diagnosed? And what is it that makes it so hard, often or so difficult for people to get that proper diagnosis?
[00:23:02] Speaker B: Yeah, I think that's an excellent question. And I think just looking back at my own schooling, it makes a lot of sense why this is an underdiagnosed disorder. I'm thinking about my MSW program.
I went to a great program, but we did not touch on OCD really, at all.
So I think, first and foremost, people just don't know what to look for. It's not necessarily on their radar when a kid or an adult really is coming into their, you know, therapy office. So I think that's the first thing. And the second piece is that I think that OCD can look like so many other disorders. I'm thinking about trauma, which is where a lot of my background as a clinician comes from.
And with trauma, there are often a lot of, you know, repetitive behaviors that can come up. So somebody, you know, you know, checking the doors and windows, sort of like seeking safety. And that could be 100% a trauma response to, you know, a real event that they experience. But that also can overlap with how OCD might look.
There's also a ton of avoidance, hypervigilance.
All of these things sort of look very similar. So I think it can be challenging for clinicians, especially if OCD is not on your radar, to parse apart all of these different diagnoses and really get to the root of, you know, the challenge here for a kid. But I think it's incredibly important to find that accurate and effective care.
There was a study that was released by the International OCD foundation just a couple of days ago that said that 95% of Americans living with OCD don't receive effective treatment.
And we know that OCD comes with a lot of shame. And when you're not able to, like, accurately speak to your experiences in therapy, that shame just starts to compound.
I think it's been really meaningful for me as a clinician to name OCD and sort of put it in the room for patients and parents and have them have that look on their face that says, wow, yeah, that's exactly what I'm experiencing. I haven't had anybody share that with me before.
It helps them feel less alone. It helps to break down some of that shame and stigma, especially when we're thinking about four taboo forms of OCD that might come up in those different themes.
So I just think from like a mental health and wellness and rapport building perspective, it's so important. And then of course, being able to get them the type of treatment that's going to get them back into their life and less impacted by these OCD symptoms, it's so powerful.
The last thing I'll kind of say about this question too is that we know that OCD tends to be a lifelong illness. It's not something that, you know, is easily resolved and people don't have to experience it later on in life.
So again, having kids be armed with the tools that says, oh, yeah, when my OCD pops up six months in the future, a year in the future, even once treatment is done, I know what I need to do to be able to combat those symptoms is so powerful. We're really giving back their autonomy and I love that. It's what I find most meaningful about this work.
[00:26:42] Speaker A: Imagine that, like, it makes it easier, like when it pops up again, to be able to name it and jump on it quicker before, you know, it takes over. So thank you so much for the work that you're doing. You know, I think we all have someone we love who has struggled with ocd and, you know, it's so important. And I really appreciate time you took Brianna to share with us and give us some insights and how as, as therapists, we can kind of look out for it and also not feel ashamed ourselves of asking for help when we bump up against a case that, you know, maybe could benefit from a training that is beyond our scope.
[00:27:24] Speaker B: Absolutely. Thank you, Anna. This has been so fun. I appreciate it.
[00:27:28] Speaker A: Likewise.
Thanks so much, Brianna. Have a great day.
