The Holidays: Exposed
In this Q&A with Keeleigh Mahler, MSW, she shares approaches for helping residents engage the stresses of the holiday season head-on as important opportunities for growth. By treating these concentrated experiences of social and familial pressure as ERP exposures, holiday home visits become powerful therapeutic experiences and confidence builders for our residents.
MV: So, folks are getting ready for the holidays, which of course are supposed to be a time of celebration. But we know that for many of our residents it is a time of escalated anxiety. What are some of the contributors to that anxiety?
Keeleigh: Expectations are a big one. Many of us enter the holidays with unexamined expectations. We might fearfully expect the worst, or we might have unrealistically inflated expectations. This sets the stage for anticipatory anxiety on the one hand or disappointment on the other. For young people struggling with anxiety or a related disorder, these normal holiday emotions can be overwhelming and highly dysregulating. Also, for a young person in treatment, the holidays can include mixed company and result in awkward questions from well-meaning family members who might not be in the know regarding treatment.
MV: So how do you address those issues?
Keeleigh: Well, first we explore those expectations. Sometimes I will have a resident do some visualization; they imagine and describe their best holiday and their worst holiday to compare those two extremes. It helps us sort of “right size” their expectations and imagine maybe some more realistic in-between possibilities. From there we can have a more realistic conversation about what they might experience and what they might want to have happen. We can also begin to explore more concretely some of the situations and challenges that might come up. Maybe prepare in advance for some of the awkward questions from grandma or grandpa that we assume they are going to ask.
MV: What kinds of questions are you talking about?
Keeleigh: You know, questions about school or what the resident is doing without realizing the resident is in treatment. Or, for those who do know, questions specifically about treatment like, “are you making progress?” Even questions about coping methods the resident may be employing, you know, like “Why can’t you sit with us through the whole dinner?” Food related questions can be a challenge for some of our residents, like a well-meaning grandmother asking, “why aren’t you eating your food?” So, often we will role play, and I will kind of grill them a little bit so they can practice what they might say or, in some cases, not say under duress. Some residents decide they don’t want their treatment to be disclosed and that can be complicated and anxiety producing in itself-this idea of having a secret. We work on how the resident can manage the conversation such that they are answering truthfully without disclosing what they choose not to disclose; the goal is to help them confidently manage these boundaries while retaining a strong sense of authenticity and “living in their own truth.”
MV: Are parents part of this preparatory work?
Keeleigh: Absolutely. We bring all of this to family sessions so that parents can also adjust their own expectations to align with their child’s needs and goals and so that they can enter the holidays as allies with their child and active supporters of their treatment objectives. I facilitate these conversations both to address the specific holiday at hand and to teach them how to engage in these conversations on their own after Mountain Valley. We also work with the resident and the family to create a written road map, a contract, so to speak, for the holiday. It might include a schedule of planned events so that the resident can anticipate and manage energy levels, monitor stress levels, plan breaks, and build in nervous system reset strategies like walks, intense exercise, paced breathing, progressive muscle relaxation, and cold showers. Things they practice while here. The plan might even call for having a smaller family gathering than usual this year. We do a lot of visualization and strategizing. All strategies that benefit from a team approach and a shared plan.
MV: So, is the resident viewing the holiday as a stressful interruption to treatment with the goal of just making it through unscathed and returning to Mountain Valley intact, or is it viewed more as part of the program, i.e. one big opportunity for exposure and growth?
Keeleigh: It’s exposure. We have goals for it. If our intention was for you to just get through it, then we’d have to assume that you were never going to have another Christmas or holiday again. We very much view it as an opportunity to engage a very stressful situation with a growth mindset; what can we do to maintain progress while also being flexible, compassionate, and realistic. Like, we’re not going to set a goal that a socially anxious resident is going to give a big speech, say the prayer, and carve the roast. With all the additive stress of a holiday, just sitting through a meal might be a success worthy of celebration.
MV: How do residents evaluate their experience while at home? How do they know they are on track and making progress.
Keeleigh: They get in a routine of using the SUDS (subjective units of distress scale) rating scale while here and, of course, they bring that home with them on their holiday visit. We usually give them homework to use their SUDS scale to measure three emotions three times a day-morning, noon, and night-so that they are routinely monitoring the state of their nervous system. Again, to create alignment and support, we encourage the parents to participate in this activity and monitor their own SUDS scale. Residents also have specific action goals that serve as concrete measures of progress. Finally, we like to remind our residents that you sometimes have to just “get up and shake your butt.” In other words, just move, shake it out, be a little silly, have some fun. Life doesn’t have to be so serious. For our residents, who are so smart and sensitive and, often, serious, that’s an important practice.