Editor’s note: The following is an interview with Christopher McCurry, PhD, a clinical child psychologist in private practice specializing in the treatment of childhood anxiety. Dr. McCurry is a clinical assistant professor in the departments of psychology and psychiatry at the University of Washington in Seattle, WA. He is the author of Parenting Your Anxious Child with Mindfulness and Acceptance.
Praxis: How did you become interested in working specifically with children?
CM: I became interested in working with children through some early work—in graduate school—with young adults with developmental disabilities. This led me to clinical research on early intervention programs in hopes of preventing problems down the road, and subsequently, to working with young children of all kinds.
Praxis: What are some of the things that need to be adapted when doing acceptance and commitment therapy (ACT) with children that may pose a challenge for clinicians who are already well-versed in ACT work?
CM: Many of the same issues and adaptations are needed in doing individual psychotherapy of any kind with children—limited capacity for reflecting on thoughts and feelings especially when time (past or future) gets thrown in; a reticence to acknowledge problems (saving face); and the complications imposed by necessarily working with important adults such as parents and teachers, to name a few.
The result is more emphasis on short-term goals—and perhaps goals that initially seem distant from what the adults are looking for—so that the therapist can engage the child in a therapeutic alliance.
With ACT specifically, one can’t get too abstract or wordy, especially with children under the age of ten. Children do like metaphors, stories and experiential exercises that are active and fun. ACT work is often used in conjunction with other child behavioral interventions such as reward programs, parent management practices, exposure/response prevention, and skill building.
Praxis: What are some of the benefits of working with children when doing ACT work that makes things easier than doing the work with adults?
CM: Children are, I think, living every day with figurative language: metaphor, fables, thinking imaginatively and creatively. They delight in the ACT metaphors and in new ways of looking at the world. Adults often come into therapy a tad rigid and with a “just give me the answer” stance that grates against “don’t believe everything you believe,” and other ACT paradoxical language.
Children often have not reflected on their thinking or articulated the verbal rules they live by. Helping a child step back from his or her thinking (what the modern analysts call mentalizing), can be powerfully liberating. You can preclude a lot of future psychological inflexibility by developing these insights and habits early on.
Praxis: You specialize in working with children who experience anxiety. Why is it that ACT is so well-suited to this specific population?
CM: Anxiety yields well to ACT in part because there is an inherent and immediate tension between the anxious or fearful thoughts and feelings and what individuals want for their life. This makes it relatively easy to talk about valued goals and accepting what lies between you and moving toward that goal.
The concepts and metaphors (e.g., willingness, the chessboard) are hugely effective in getting people unstuck and experiencing a difference in life without the necessity of changing, in the short run, how they are thinking and feeling.
Praxis: What has the research shown thus far about doing ACT with children?
CM: The research with children is growing, but still quite sparse and lacking in randomized control designs. Swain et al 2015 is a good recent review. The vast majority of ACT intervention studies with “children” in fact involve adolescents.
Despite methodological issues, the research generally supports ACT as an effective intervention for a variety of concerns and issues, from tic disorders to eating disorders, depression, even high-risk sexual behaviors.
One promising area of clinical intervention is in autism spectrum disorders; for example, increasing perspective-taking in young individuals, as well as addressing stress and coping in their parents.
Praxis: Aside from anxiety, what are some of the emotional and behavioral issues that children experience that are particularly well-suited for ACT interventions?
CM: As mentioned above, ACT is showing promise with a number of emotional and behavioral issues: impulse control disorders (ADHD, OCD, and trichotillomania), chronic pain, depression, and PTSD.
ACT is a transdiagnostic approach; it focuses on the common processes that keep people stuck or that allow growth and a vital life, e.g., psychological flexibility. As such, it has wide application across the traditional diagnostic categories.
There is a lot of acceptance involved in parenting, a lot of willingness, and a lot of keeping your eye on the valued goal. I explicitly teach ACT metaphors and concepts to the parents so that they can model psychological flexibility for the child in difficult moments and also use these tools themselves as they navigate the day-to-day life of the family while experiencing their own wide and powerful range of thoughts, verbal rules, feelings, and memories.
Praxis: Certainly the parent or caregiver plays an important role in the therapeutic process when working with children. Do you think that the skills taught in ACT work lend themselves well to fostering parent participation, and otherwise engaging parents effectively?
CM: I work a lot with parents, especially with very young children (e.g., four and five-year-olds). They are like my assistant coaches out in the world where the interesting events are happening.