What to Do When Worries Ring True: How CBT Clinicians Can Address Realistic Worries When Treating Youth With Anxiety

ABSTRACT

Cognitive-behavioral therapy (CBT) is effective for many youth who are struggling with anxiety. Yet, the straightforward applications of CBT skills for youth anxiety that are presented in CBT manuals tend to assume that clients’ worries are very unlikely to occur and/or that clients are “catastrophizing” about potential outcomes. The examples provided in manuals often suggest that, by implementing CBT skills, clients will discover that they have been overestimating risk, which will decrease their anxiety. In practice, clinicians frequently treat youth who present with worries that are more realistic – that is, they align with youths’ prior experiences and/or reflect true possibilities of negative outcomes. Clinicians who are treating these youth may question the appropriateness of CBT and wonder how to proceed with treatment. In this practical paper, we discuss the scope and applications of CBT skills when treating youth who are experiencing realistic worries. In line with flexibility within fidelity, we provide recommendations on how to assess and conceptualize youth anxiety and how to tailor core CBT strategies for this population of anxious youth. We illustrate our recommendations with a range of case examples. We intend for this resource to help enhance the applicability and effectiveness of CBT so that the greatest possible number of youth are able to benefit from treatment.

Acknowledgments

We sincerely thank our colleagues Annie Dantowitz, Kelsey Hudson, and Alicia Fenley for their collaboration in developing the recommendations described throughout this manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Author positionality

The authors are clinical psychologists with faculty appointments at universities located in large metropolitan areas on the East Coast of the United States. As clinicians, all authors specialize in working with children, adolescents, and families. Their research broadly focuses on increasing access to effective and culturally responsive mental health services. At the time of writing this manuscript, all authors identified as cisgender women. Three authors identified as White, and one author identified as Cuban-American. This manuscript is not only based on the authors’ own clinical experiences, but also their experiences working with and learning from community clinicians in the context of training, consultation, and research.